COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64058824 
1D151  Un3  AbstracteoLwarsuL 

RECAP 


fill  I  ft 


u*  3 


Columbia  <Bntoer*ttj> 

College  of  ^Ijpssictang  ano  gmrgeons 
JLibxavv 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/abstractsofwarsuOOunit 


ABSTRACTS  OF  WAR  SURGERY 


ABSTRACTS 

OF 

WAR    SURGERY 


AN  ABSTRACT  OF  THE  WAR  LITERATURE  OF  GENERAL 

SURGERY  THAT  HAS  BEEN  PUBLISHED  SINCE 

THE  DECLARATION  OF  WAR  IN  11)14 


PEEPAEED   BY   THE   DIVISION   OF   SURGERY.   SURGEON- 
GENERAL'S   OFFICE 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1918 


Copyright,  1918,  By  C.  V.  Mosby  Company 


Press  of 

C.    V.    Mosby    Company 

St.    Louis 


PREFACE 


The  preparation  of  these  abstracts,  in  common  with  many  of 
the  other  early  war  activities,  was  an  emergency  war  measure. 
Much  of  the  excellent  surgical  work  which  had  developed  as  a 
result  of  French,  English  and  Italian  effort  had  to  be  appropri- 
ated by  our  medical  personnel  at  a  time  least  favorable  for  quiet 
mental  effort. 

To  meet  the  needs  of  the  situation,  the  Division  of  General 
Surgery  of  the  Surgeon  General's  Office  prepared,  collected  and 
arranged  abstracts  of  the  important  general  surgical  papers  bear- 
ing on  war  surgery;  and,  after  having  them  mimeographed,  dis- 
tributed one  hundred  of  them  to  various  surgical  instructors  in 
the  Army  Surgical  Schools,  and  to  the  surgical  chiefs  of  the  war 
hospitals.  This  limited  issue  of  one  hundred  so  far  failed  to 
meet  the  demand  that  we  have  acceded  to  the  request  for  a  wider 
distribution  in  printed  form. 

The  volume  must  of  necessity  be  regarded  merely  as  a  con- 
densed text  for  ready  reference.  Most  of  the  abstracts  have 
been  used  through  the  courtesy  of  Surgery,  Gynecology  and  Ob- 
stetrics, the  Journal  of  the  American  Medical  Association,  the 
Medical  Record,  the  Military  Surgeon,  and  the  New  York 
Medical  Journal.  Some  articles  in  the  British  Medical  Journal 
and  in  Surgery,  Gynecology  and  Obstetrics  were  so  fundamental 
that  they  were  abstracted  with  a  minimal  amount  of  paraphrase. 
To  all  these  journals  and  to  any  others  that  through  inadvertence 
may  not  have  been  mentioned,  we  express  the  sincere  thanks  of 
the  Surgeon  General. 

Washington,  D.   C. 
May  29,  1918. 


CONTENTS 


GENERAL  TOPICS 

PAGE 

The  Development  of  British  Surgery  at  the  Front.     Surgeon-General  Sir 

Anthony  Bowlby  and  Colonel  Cuthbert   Wallace 17 

Development  of  British  Surgery  in  the  Hospitals  on  the  Lines  of  Com- 
munication in  France.     Surgeon-General  Sir  George  H.  Malcins     .     .       47 

WOUND  INFECTION  AND  TREATMENT 

Gunshot  Wounds  and  Their  Treatment.     Sir  Berkeley  Moynihan     ...  83 

Wound    Excision 97 

Wound  Infections:  Some  New  Methods  for  the  Study  of  the  Various 
Factors  Which  Come   Into   Consideration   in   Their   Treatment.     A. 

E.    Wright 103 

Treatment  of  Infected  Suppurating  War  Wounds.     Butherford  Morison  106 

Treatment  of  Infected  Wounds  by  Physiological  Methods.    A.  E.  Wright  107 

Experiences   of   a   Consulting   Surgeon.      Enderlen 109 

The  Advanced  Surgical  Post.    J.  and  P.  Fielle 110 

The  Working  of  a  Clearing  Ambulance.     A.  Latarjet Ill 

Interallied  Surgical  Commission  on  Treatment  of  Wounds 112 

The  Bacteriology  of  Septic  Wounds.     A.  Fleming 113 

Cicatrization    of    Wounds;    The    Use    of    Chloramine-T    Paste    for    the 

Sterilization  of  Wounds.     M.  Daufresne 116 

Cicatrization  of  Wounds;  Sterilization  of  Wounds  With  Chloramine — T. 

A.  Carrel  and  A.  Hartmann 117 

Sterilization  of  War  Wounds.    Dehelly  and  Dumas 120 

Considerations  on  Some  War  Injuries  After  Eighteen  Months  of  Cam- 
paign.    B.   Proust 120 


TETANUS 

Antitoxin  Content  of  the  Serum  of  Tetanus  Patients.     H.  Wints     .     .  122 

Treatment    of    Tetanus.      T.   Kocher     .' 122 

Intraspinal  Administration  of  Antitoxin  in  Tetanus.    M.  Nicoll,  Jr.     .     .  123 
Treatment  of   Tetanus  by  Endoneural  Injection  of  Antitetanus  Serum 

and  Drainage  of  the  Nerve.     F.  Kempf 124 

Late  Tetanus.     L.  Berard 125 

Clinical  and  Therapeutical  Experience  With  Tetanus.     B.  O.  Pribram     .  125 
Intraneural  Injection  of  Tetanus  Antitoxin  in  Local  Tetanus.    A.  Meyer  127 
Statistics  of  Cases  of  Tetanus  Observed  in  the  War  Zone  from  Novem- 
ber 1,  1915,  to  February  1,  1917.     P.  Chavasse 127 

Local   Tetanus.     F.   Brunsel 128 

11 


12  CONTENTS 

PAGE 

A  Eeport  on  Twenty-five  Cases  of  Tetanus.    II.  E.  Dean 129 

The    Intrathecal    Route    for    the    Administration    of    Tetanus    Antitoxin 

F.  W.  Andrews 131 

A    Comparison    of    Subcutaneous    with    Intravenous    Administration    of 

Tetanus  Antitoxin  in  Experimental  Tetanus.     F.  Golla 131 

Tetanus   in   War 132 

GAS  GANGRENE 

Gas  Gangrene.     (Anaerobic,  Acute  Bacillary,  or  War  Gangrene)     .     .     .     138 

Gas  Phlegmons  on  the  Field.     G.  Seefisch 163 

Treatment  of  Gas  Phlegmon  in  the  Field.     W.  Becker 163 

ABDOMEN 

A  Series  of  500  Cases  of  Emergency  Operations  for  Abdominal  Wounds. 

C.  F.  Walters,  H.  D.  Eollinson,  A.  E.  Jordan,  and  A..  G.  Banks     .     .  165 

Stab  and  Gunshot  Injuries  of  the  Abdomen.     S.  Basdekis 177 

Treatment   of   Abdominal   Injuries   at   the    Front.     Schwartz.      Thirty- 
three   Laparotomies   in   Cases   of   Abdominal   Injury.     Bouvier   and 

Caudrelier 179 

Suture  of  the  Diaphragm  for  Gunshot  Wound  with  Hernia  of  Omentum 

and   Transverse   Colon.     0.   Ortali 181 

New  Series  of  Abdominal  Wounds  Treated  in  Automobile  Surgical  Am- 
bulance  No.   2.     H.   Eouvillois,    Gmllaume-Loms,    and   Basset     .     .  182 

War  Wounds  of  the  Spleen.     Fiolle 182 

Prognosis  and  Treatment  of  Abdominal  War  Injuries.     Most     ....  183 

Gunshot  Wounds  of  the  Abdomen.    Kort  and  Schmieden 185 

Necessity  for  Systematic  Operation  in  Abdominal  Wounds.    E.  Leriche     .  186 
Operative   Treatment   of    Gunshot   Injuries   of   the   Intestine.     Enderlen 

and  Sauerbruch 187 

The   Surgical   Ambulance    and   Abdominal   Wounds.      U.    Calabrose    and 

B.  Eossi 188 

Abdominal  Injuries  in  a  Casualty  Clearing  Station.    A.  Don 188 

Intraperitoneal  Rupture  of  the  Bladder.     F.  Eost 189 

Early  Treatment  of  Gunshot  Wounds  of  the  Alimentary  Canal.   C.  Wallace  190 
Foreign  Bodies  in  the  Bladder  Resulting  from  Gunshot  Wounds.     G.  G. 

Turner 195 

Treatment  of  Gunshot  Wounds  of  the  Bladder.     V.  Saviozsi     ....  196 

Intraperitoneal    Bladder    Wounds.      E.    Brin 197 

The  Treatment  of  Simultaneous  Lesions  of  the  Rectum  and  Bladder.    F. 

Crosti 198 

Surgical  Treatment  of  War  Wounds  of  the  Abdomen 199 

CHEST 

Gunshot  Wounds  of  Lungs  and  Pleura.     Sir  Berkeley  Moynihan     .     .     .     207 
Treatment  of  Penetrating  Gunshot  Wounds  of  the  Chest.    X.  Delore,  and 

L.  Armand 216 


CONTENTS  13 

PAGE. 
Is  Thoracotomy  Indicated  in  the  Treatment  of  Wounds  of  the  Chest  to 

Arrest  Hemorrhage?     Hartmann 217 

Infection   of   Hemothorax   by   Anaerobic   Gas-producing   Bacilli.      T.   B. 

Elliott 218 

Projectiles  in  the  Pleural  Cavity;  Different  Behavior  of  the  Pleura  Ac- 
cording to  the  Form  of  the  Projectile.     G.  Crcsole 220 

Extraction  of  Intrapulmonary  Projectiles  Under  the  Screen.     E.  Petit  de 

la   Villeon 220 

Technie  of  the  Extraction  of  Foreign  Bodies  in  the  Mediastinum,  by  the 
Transpleural  Route  with  an  Anterior  Costal  Opening  and  Other  Meth- 
ods;   Operative   Results.     B.   Le  Fort 221 

Extraction  of  Intrathoracic  Projectiles.     Binet  and  Masmenteil     .     .     .  223 

War  Wounds  of  the  Larynx  and  Trachea.     E.  J.  Moure 223 

Penetrating  Wounds  of  the  Thorax.  E.  Bemond  and  B.  Glenard  .  .  225 
Gunshot    Wounds    of    the    Larynx    and    Trachea.      K.    Kofler,    and    V. 

Fruehwald 226 

War   Wounds    of    the    Lung 227 

Gunshot  Wounds  of  the  Lungs,  and  Tuberculosis.     H.  Bieder     ....  244 

CARDIOVASCULAR  SURGERY 

Injury  of  the  Heart  by  the  Bursting  of  a  Grenade;  Extraction  of  Pro- 
jectile from  the  Right  Ventricle;   Recovery.     Beaussanat     ....  245 
Conservative  or  Operative  Treatment  of  Heart  Wounds.    A.  S chafer     .     .  245 

Vascular  Injuries  in  War 246 

Further  Experience  with  Aneurisms  in  War,  with  Special  Reference  to 

Suturing  the  Vessels.    H.  von  Haberer 273 

Experience    with    Vascular    Injuries 274 

JOINTS 

Practical  Points  on  the  Use  of  Immobilization  in  War  Surgery     .     .     .  276 

Wounds    of    Joints 285 

Articular    Gunshot   Wounds.      Hatter 295 

Resection  of  the  Knee  to  Avoid  Amputation  of  the  Thigh  in  Fractures 

of  the  Knee.     Tuffier 296 

Treatment  of  Gunshot  Wounds  of  the  Knee-Joint.     H.  M.  TV.  Gray     .     .  297 

Resection  of  the  Shoulder  in  War  Surgery.    Fourmestrcuux 298 

Primary  Resection  in  the  Treatment  of  Articular  Gunshot  Wounds  with 

Fractures.     G.   Cotte 299 

Treatment  of  Traumatic  Arthritis  of  the  Knee.     Marchah  and  Dupont     .  301 

Communication  from  U.  S.  Army  Base  Hospital  No.  5.  B.  B.  Osgood  .  303 
The  Immediate  Results  of  Surgical  Intervention  in  111  Cases  of  Purulent 

Arthritis  of  the  Large  Articulations.     Auvray 304 


14  CONTENTS 

PAGE 

Arthrotomy  Followed  by  Immediate  Closure  of  the  Articulation  in  the 
Treatment  of  Certain  Wounds  of  the  Knee.     M.   Gaudier  and  E. 

Montaz 305 

Treatment  of  Gunshot  Wounds  of  Knee-Joint.     H.  M.  W.  Gray     ...  306 

Treatment  of  Wounded  Knee-Joint.     H.  G.  Barlmg 309 

FRACTURES 

The  Treatment  of  Gunshot  Fractures.    E.  W.  PL.  Groves  and  T.  H.  Brown  311 

Treatment  of  Shell  Fractures  of  the  Femur.    E.  SuchaneTc 311 

Reduction  of  the  Number  of  Amputations  at  the  Front.    E.  Marquis     .     .  312 
Primary  Transformation  of  Open  Gunshot  Thigh  Fractures  Into  Closed 

Fractures.     Lagoutte 313 

Infected  Gunshot  Injuries  of  Bones  and  Joints.     W.  Derik 314 

An  Important  Point  in  the  Treatment  of  Gunshot  Fractures.     G.  Perthes  315 

The  Plating  of  Gunshot  Fractures.    N.  C.  Lake 315 

Thigh  Amputations  in  War  Surgery:  46  Cases.    A.  Chalier 315 

Primary  Resection  in  Articular  Wounds  of  the  Knee.     PL.  P.  Bouvillois, 

L.  Guillaume  and  Basset 319 

Functional  Value  of  the  Stump  after  Amputation.     Tuffier 319 

Treatment  of  Complicated  Gunshot  Fractures  of  the  Humeral  Diaphysis. 

H.  Alamartine 320 

Early  Treatment  of  Compound  Fracture  of  the  Long  Bones  of  the  Ex- 
tremities.   B.  Hughes 321 

Secondary  Suture  of  the  Wound  in  Cases  of  Open  Fracture.     Depage 

and  Vandervelde 323 

Diagnosis  of   Suppurative  Arthritis   Following   Gunshot  Fractures.     M. 

Chaput 324 

Treatment  of  Gunshot  Injuries  of  the  Extremities.    Axhausen     ....  325 

Treatment  of  Gunshot  Fractures  of  the  Extremities  in  War.    G.  von  Soar  326 

Ten  Rules  for  Amputations  of  the  Lower  Limbs.    B.  Bitschl 327 

BURNS 

Paraffin  Treatment  of  Burns.     Maj.  Geo.  de  TarnowsJcy 328 

Paraffin  in  the  Treatment  of  Wounds  and  Burns.    Observations  on  Various 

Preparations.    J.  B.  Beiter 331 

ANESTHESIA  IN  WARFARE 

Anesthesia  in  Warfare.     Paluel  J.  Flagg 335 

Anesthetics  at  a  Casualty  Clearing  Station.     G.  Marshall 346 

TRENCH-FOOT 

Trench-Foot.     E.   M.   Frost 349 

Trench-Foot 350 

Shock  as  Seen  at  the  Front.    E.  Archibald  and  J.  W.  Maclean     .     .     .  352 

Surgical  Shock 353 

Fluid  Substitutes  for  Transfusion  in  Shock  and  Hemorrhage     ....  363 


CONTENTS  15 

FOREIGN  BODIES 

PAGE 

Simple  Method  of  Localization  of  Foreign  Bodies.     ./.  S.  Young     .     .     .  368 

The  Localization  of  Foreign  Bodies.     TV.  A.  Wilkins 368 

The  Sutton  Method  of  Foreign  Body  Localization.     E.  H.  Skinner     .     .  369 
Operative  Removal  of  Bullets  and  Fragments  of  Grenades,  With  Special 

Reference  to  the  Use  of  the  Electromagnet.     Von  Hofmeister     .     .     .  370 

PERIPHERAL  NERVE  INJURIES 

Injury  to  Peripheral  Nerves.     Sir  Berkeley  Moynihan 372 

The  Treatment  of  Peripheral  Nerve  Injuries 381 

The  After-Care  of  Nerve  Injuries 391 

JAWS  AND  FACE 

Early  Care  of  Gunshot  Wounds  of  the  Jaws  and  Surrounding  Soft  Parts  398 
Surgical  and  Prosthetic  Treatment   of   Fractures  of  the  Jaws  by  War 
Projectiles,  in  an  Evacuation  Center.    Frison,  Dufourmentel,  Bonnet- 
Boy  and  Brunet 411 

War  Injuries  of  the  Jaw.     N.  G.  Bennett 413 

Suggestions    Toward    a    Systematic    Operative    Treatment    of    Gunshot 

Wounds  of  the  Mandible.     TV.  Trotter 415 

Reconstruction  of  the  Jaws  After  War  Wounds.     E.  Matti 418 

Cases  of  Gunshot  Injury  of  the  Face  and  Jaw,  With  Special  Reference 

to  Treatment.    F.  N.  Doubleday 419 

Vincent's  Disease  of  the  Mouth  and  Pharynx.     TV.  H.  McKinistry     .     .  419 
Treatment  of  Facial  Paralysis  Due  to  Gunshot  Injury  by  Muscular  Anas- 
tomosis.   H.  Horestin 420 

Salivary    Fistula? 421 


ABSTRACTS 

OF 

WAR  SURGERY 


GENERAL  TOPICS 


THE  DEVELOPMENT  OF  BRITISH  SURGERY  AT  THE 
FRONT. — Surgeon-General  Sir  Anthony  Bowlby  and  Colonel 
Cuthbert  Wallace.    Brit.  Med.  Jour.,  June  2,  1917. 

The  Regimental  Medical  Officer. — The  duties  of  the  regimental 
medical  officer  in  this  war  are  much  the  same  as  they  have  ever 
been.  He  shares  the  dangers  common  to  the  combatant,  officers 
and  men,  and  stays  with  his  battalion  or  brigade,  as  the  case 
may  be.  His  treatment  can  only  be  that  of  first  aid,  but  he  and 
his  orderlies  have  saved  innumerable  lives,  both  by  the  rescue  of 
wounded  comrades  from  dangerous  situations  and  by  careful 
and  rapid  transport  to  the  field  ambulance  sections  in  the  sup- 
port line. 

The  Field  Ambulance. — At  the  "advanced  dressing  station," 
there  is  a  personnel  of  two  or  three  medical  officers,  noncommis- 
sioned officers,  and  orderlies,  and  it  is  here  that  the  first-aid 
dressings  can  be  supplemented  by  additional  dressings  and  by 
suitable  splints,  so  as  to  ensure  a  more  easy  transit  to  the  "tent 
section"  of  the  field  ambulance,  a  mile  or  two  farther  back. 

The  following  instructions,  which  are  amongst  those  issued  in 
all  the  "armies"  at  the  front,  will  best  indicate  the  limitations  of 
their  work: 

"  (1)  Only  operations  of  emergency  should  be  performed 
in  field  ambulances,  but  the  following  exceptions  must  be 
noted : 

"(a)  Completely  smashed  limbs  should  be  removed,  and 
the  patients  retained  for  at  least  a  day  before  being  sent  to 
a  casualty  clearing  station. 

17 


18  ABSTRACTS  OF  WAR  SURGERY 

"  (b)  Hemorrhage  should  be  arrested  by  ligature  of  bleed- 
ing points  whenever  possible.  If  this  is  not  possible,  then 
plugging  or  direct  pressure  on  the  wound  itself  should  be 
resorted  to.  Patients  should  never  be  sent  down  with  tourni- 
quets on  their  limbs. 

"(2)  Abdominal  wounds  and  all  severe  cases  requiring 
early  treatment  at  a  casualty  clearing  station  should  be  sent 
there  by  a  special  motor  ambulance  direct  from  the  advanced 
dressing  station.  They  should  not  be  kept  waiting  for  the 
regular  convoys." 

A  further  development  of  the  tent  section  resulted  from  the 
conditions  at  the  battle  of  the  Somme,  where,  on  account  of  the 
small  area  and  the  few  good  roads,  "corps  dressing  stations' 
were  created  by  joining  up  some  members  of  the  staffs  of  various 
field  ambulances,  so  as  to  supply  tent  accommodation  for  a  thou- 
sand or  more  wounded,  with  a  staff  of  about  thirty  medical  offi- 
cers. A  unit  such  as  this  performed  the  duties  ordinarily  per- 
formed by  several  separate  field  ambulances. 

Motor  Ambulances. — It  is  the  supply  of  motor  ambulances 
alone  that  has  made  it  possible  to  deal  adequately  with  the  sur- 
gery at  the  front.  One  aspect  of  this  subject,  however,  is  very 
commonly  overlooked,  namely,  the  use  of  motor  transport  in 
saving  the  wounded  from  capture,  for  there  can  be  no  doubt 
that,  had  motor  ambulances  been  supplied  in  large  numbers,  the 
tale  of  British  prisoners  after  Mons  and  Le  Cateau  would  have 
been  very  small.  The  first  complete  convoy  came  to  the  front  in 
the  middle  of  October,  and  at  the  first  battle  of  Ypres  was  of  the 
utmost  possible  value,  both  in  getting  patients  quickly  to  the 
casualty  clearing  stations  and  also  in  saving  wounded  from  fall- 
ing into  the  hands  of  the  enemy  during  the  retirement  to  the 
ground  subsequently  held. 

The  motor  ambulance,  indeed,  is  the  very  foundation  on  which 
all  surgery  at  the  front  is  based.  Without  it  the  whole  system 
would  break  down,  for  no  horsed  vehicles  could  possibly  deal 
with  the  numbers  of  a  heavy  fight  unless  they  were  so  numerous 
that  they  would  practically  block  the  roads  for  all  other  trans- 
port, and  even  then  their  slowness  would  result  in  such  delays  in 
delivery  that  surgery  would  be  of  little  use.  In  addition,  the 
well  hung  and  well  driven  motor  causes  the  patient  infinitely  less 
distress  than  the  old  ambulance  wagon,  and  so  delivers  him  in 
a  much  better  condition  for  recovery. 

The  Question  of  Time. — This  is  a  matter  of  so  much  importance 


ABSTRACTS  OF  WAR  SURGERY  10 

to  surgery  that  it  is  well  to  explain  the  time  that  is  required  to 
take  a  patient  from  the  front  trenches  to  the  casualty  clearing 
station.  It  is,  in  the  first  place,  not  sufficiently  realized  that  the 
chief  cause  of  delay,  if  it  occurs,  is  "the  enemy,"  for  there  have 
often  been,  and  there  still  are,  localities  from  which  the  wounded 
can  be  moved  only  under  cover  of  darkness,  so  that  a  man  may 
have  to  be  kept  in  a  dug-out  the  whole  of  a  long  summer's  day 
before  he  can  be  carried  to  the  rear.  Again,  in  the  desert  of  mud 
behind  the  firing  line  on  the  Somme,  stretcher-bearers  sometimes 
took  hours  to  carry  a  wounded  man  at  night  for  several  miles 
to  the  nearest  point  to  which,  in  the  absence  of  all  roads,  an 
ambulance  wagon  could  approach.  In  yet  other  cases  men  lie 
out  in  the  open  ground  on  the  so-called  -'No  Man's  Land"  for 
many  hours,  or  even  for  several  days,  before  they  are  rescued. 
But  supposing  that  none  of  these  difficulties  exist,  the  time  occu- 
pied is  very  short,  for,  if  communication  trenches  are  good,  and 
if  a  man  is  able  to  walk,  he  will  often  get  to  the  advanced  sec- 
tions of  the  nearest  field  ambulance  within  an  hour.  If  the  com- 
munication trench  is  long  and  muddy,  it  may  take  twice  that 
time.  If  he  has  to  be  carried  it  may  take  another  half-hour  or 
more,  but  as  soon  as  he  has  got  to  a  good  road  another  hour  will 
see  him  safely  delivered  to  the  place  where  his  injuries  can  be 
thoroughly  treated  and  where  he  can  be  well  nursed  under  ex- 
cellent conditions. 

All  this  is  comparatively  simple  if  no  great  battle  is  in  progress ; 
and  as  great  battles  occur  at  infrequent  intervals,  it  is  evident 
that  in  most  parts  of  the  line  of  trenches  evacuation  is  easy  and 
rapid  except  for  unusual  local  conditions.  But  in  very  heavy 
fighting,  and  especially  when  troops  are  advancing,  it  is  often 
impossible  to  find  sufficient  stretcher-bearers  in  proportion  to  the 
great  numbers  of  wounded,  for  only  a  limited  number  are  at- 
tached to  each  regiment,  and  it  is  therefore  necessarily  true 
that  the  greater  the  number  of  the  wounded  who  have  to  be  car- 
ried, the  longer  must  it  be  before  the  last  of  them  can  be  brought 
in.  No  work  is  heavier  than  stretcher  carrying  for  long  distances 
and  on  difficult  ground.  But  even  when  all  difficulties  have  been 
surmounted  and  the  patients  have  arrived  at  the  tent  sections 
of  a  field  ambulance,  there  are  many  who  are  too  much  exhausted 
for  further  immediate  moving;  and  while  the  staff  may  have 
their  hands  full  with  dressing  the  wounded,  they  have  also  to 
care  for  the  needs  of  the  many  men  who  need  to  be  rested,  fed, 
and  warmed.  While  they  are  thus  engaged  on  these  patients,  all 
those  who  require  urgent  treatment  by  operation  have  been  taken 


20  ABSTRACTS  OF  WAR  SURGERY 

direct  to  the  casualty  clearing  stations,   and  thus  have  avoided 
delay. 

The  Casualty  Clearing1  Stations. — Before  the  war  the  "C.  C. 
S.'s,"  as  they  may  be  named  for  brevity,  appeared  only  on  paper 
and  as  untried  units,  for  they  did  not  exist  at  the  time  of  the 
South  African  "War.  They  were  originally  called  "clearing  hos- 
pitals, ' '  and  their  proposed  function  was  merely  to  clear  the  field 
ambulances  and  pass  the  patients  on  to  the  base  hospitals.  Their 
equipment,  therefore,  was  only  very  slight,  and  their  staff  of 
eight  officers,  including  the  commanding  officer  and  the  quarter- 
master, was  less  than  the  staff  of  a  field  ambulance.  They  car- 
ried 200  stretchers,  and  were  supposed  to  be  able  to  deal  with  the 
same  number  of  patients. 

These  hospitals  are  situated  behind  the  line  of  trenches  along 
the  entire  front,  and  certain  local  conditions  are  essential  for 
the  success  of  their  work.  First,  they  must  be  at  or  near  to  rail- 
way sidings,  so  that  evacuation  by  train  is  easy.  Secondly,  they 
must  be  where  good  roads  can  connect  them  with  the  front. 
Thirdly,  they  must  have  a  good  water  supply. 

They  are  arranged  in  practically  two  series:  (1)  Those  nearest 
the  front  are  at  a  distance  of  from  six  to  nine  miles  from  the 
front  trenches;  (2)  those  of  the  second  line  are  from  three  to  six 
miles  further  back,  and  act  as  a  reserve  during  active  opera- 
tions, or  as  units  for  special  cases  during  quieter  times. 

The  casualty  clearing  stations  vary  greatly  in  their  accommo- 
dation, according  to  the  size  of  the  buildings  they  may  occupy, 
or  to  the  amount  of  ground  available  for  huts  or  tents  when  they 
are  encamped-  The  smallest  accommodate  400  to  500,  and  the 
largest  from  800  to  1,200.  Their  staff  is  reinforced,  as  may  be 
required,  from  other  casualty  clearing  stations  less  actively  em- 
ployed, and  from  the  staffs  of  the  field  ambulances. 

Whenever  possible  the  casualty  clearing  stations  at  the  front 
are  linked  in  pairs,  and  take  in  the  wounded  alternately.  In  this 
way  it  can  be  arranged  that,  after  admitting  as  many  as  can  be 
adequately  treated,  the  wounded  are  diverted  to  the  other 
casualty  clearing  station,  and  the  staff  is  left  free  to  treat  those 
they  have  admitted,  without  being  disturbed  by  fresh  arrivals. 

Operating"  Theaters. — When  a  casualty  clearing  station  is 
housed  in  buildings  these  theaters  must,  of  course,  vary  in  size 
with  the  accommodation  afforded.  In  the  hutted  or  tented  hos- 
pitals, however,  which  are  the  most  numerous,  the  operating  the- 
ater is  a  hut  about  60  by  20  feet,  giving  space  for  four  tables, 


ABSTRACTS  OF  WAR  SURGERY  21 

and  for  sterilizing  and  store  rooms.  Large  theaters  are  essential 
in  dealing  with  large  numbers. 

The  Treatment  of  Wounds  in  the  Casualty  Clearing  Stations. — 
It  is  the  object  of  every  casualty  clearing  station  to  treat  and 
retain  all  patients  until  they  can  be  safely  sent  down  by  ambu- 
lance train.  In  times  of  comparative  quiet  there  is  no  difficulty 
in  attaining  this  ideal,  and  consequently,  any  standard  of  treat- 
ment required  from  the  surgical  standpoint  can  ordinarily  be  at- 
tained. In  times  of  heavy  fighting,  and  especially  when  there 
is  the  certainty  that  many  more  wounded  will  arrive  during 
periods  extending  over  days  or  weeks,  it  is  evident  that  the  pro- 
vision of  empty  beds  necessitates  sending  patients  away  who 
might,  with  advantage,  be  retained  a  little  longer.  This  pressure, 
however,  does  not  prevent  the  performance  of  all  necessary 
operations,  and  those  are  now  always  performed.  If  the  re- 
quirements of  our  army  did  not  place  a  limit  on  the  number  of 
surgeons,  nurses,  orderlies  and  patients  who  can  be  retained  in 
close  proximity  to  the  fighting  line,  there  would  be  no  reason  why 
all  patients  should  not  be  kept  near  the  front.  It  must  be  re- 
membered that  if  many  hundreds  of  patients  were  kept  in  every 
casualty  clearing  station  the  staff  of  nurses  and  orderlies  would 
be  so  much  occupied  in  dressing  and  caring  for  them  that  they 
would  not  be  free  to  attend  to  the  wants  of  the  recently  wounded 
men  coming  in  convoys  from  the  field  ambulances. 

For  more  than  two  years  it  has  been  the  deliberate  policy  of 
the  British  Army  Medical  Service  to  make  the  casualty  clearing 
station,  rather  than  the  field  ambulances,  the  chief  place  for  the 
treatment  by  operation  of  the  dangerously  wounded  man  who  re- 
quires prompt  treatment. 

Dressing  and  Distribution  of  the  Wounded  at  a  Casualty  Clear- 
ing Station. — It  is  now  the  custom  of  all  casualty  clearing  sta- 
tions to  dress  their  patients  in  large  reception  huts  or  tents  as 
soon  as  they  arrive,  and  to  distribute  them  from  this  place  in  three 
classes:  (1)  For  immediate  evacuation;  (2)  for  retention;  (3) 
for  operation.  In  the  first  class  are  included  chiefly  the  slightly 
wounded.  In  the  second  class  are  patients  suffering  from  shock, 
from  the  effects  of  bleeding,  from  wounds  of  the  lung,  from  ex- 
posure to  cold,  etc.  In  the  third  class  are  all  serious  wounds  of 
the  soft  tissues  which  require  thorough  dressing,  and  especially 
lacerated  wounds  due  to  shells  and  bombs;  most  fractures; 
many  injuries  of  vessels ;  all  perforating  abdominal  wounds,  etc. 
The  proportion  of  cases  requiring  operations  to  the  whole  num- 
ber of  wounded  will  depend  on  many  conditions — for  example, 


22 


ABSTRACTS    OF   WAR   SURGERY 


the  larger  the  proportion  of  shell  wounds  to  bullet  wounds  the 
larger  is  the  number  requiring  operation,  and  if  a  train  is  wait- 
ing to  go  to  the  base,  men  may  be  sent  by  it  who  would  require 
operation  if  they  had  to  be  kept  for  thirty-six  hours.  But  it 
may  be  stated  in  general  terms  that  the  proportion  of  patients 
treated  under  anesthetics  may  be  as  high  as  one  in  four,  but  it  is 
more  often  about  one  in  six. 

The  following  table,  compiled  by  Captain  Hey,  who  is  the 
Surgical  Specialist  at  one  of  the  forward  casualty  clearing  sta- 
tions, will  give  a  very  good  idea  of  the  operative  work  of  a  par- 
ticular unit,  and  it  includes  a  period  of  heavy  fighting  during  a 
recent  battle. 


Table  of  Operations  Performed  at  a  Casualty  Clearing  Station. 


A. 


B. 


Ligature  of  arteries: 

Carotid 5 

Vertebral    

2 

Subclavian    

2 

15 

39 

Radial    

18 

Ulnar    

8 

Ext.  iliac   

2 

51 

31 

16 

58 

Various 

30 

277 

For  treatment  of  fractures: 

Skull 189 

18 

298 

133 

299 

Leg   

309 

38 

119 

1,403 

For  treatment  of  joints: 

Knee 183 

Other  joints   

64 

247 


ABSTRACTS   OF    WAR   SURGERY 


23 


Amputations: 
Shoulder  joint 
Upper  arm    .  . . 

Forearm 

Thigh    

Knee   , 

Leg    

Ankle    

Various    


14 
77 
31 
186 
10 
76 
6 
31 


431 


E. 

For  drainage  of  pleura 

49 

F. 

For  wounds  of  the  abdomen 

106 

G. 

Removal   of   testis 

33 

H. 

For  ruptured  urethra 

9 

J. 

Enucleation  of  eye 

43 

K. 

Plastic  operations 

33 

T, 

Tracheotomy    

17 

280 

M. 

Excision  and  cleansing  of  wounds: 

Head  and  neck 

95 

Trunk  

309 

Upper  Limb 

249 

765 

Multiple 

398 

1,816 


N.    For  conditions  not  due  to  gunshot  wounds. 

Appendicitis 

Strangulated   hernia 

Cellulitis 

Various 


34 

1 

53 

13 


It  will  be  seen  that  the  total  number  of  operations  performed 
for  gunshot  wounds  amounts  to  4,554,  and  the  total  number  of 
wounded  admitted  during  the  period  in  question  was  20,589  in 
this  particular  unit.  It  will  be  noticed  that  a  very  large  majority 
of  the  operations  were  for  fractures  of  the  limbs  and  wounds  of 
the  soft  tissues  which  required  complete  surgical  clearing.  The 
proportion  of  abdominal  operations  would  have  been  higher  but 
for  the  fact  that  an  "advanced  operating  center"  was  near  at 
hand,  and  took  charge  of  many  cases  of  this  class. 

During  heavy  fighting,  operative  work  such  as  the  above  goes 
on  continuously  day  and  night,  and  consequently  necessitates 


24  ABSTRACTS  OF  WAR  SURGERY 

relays  of  surgeons,  nurses,  and  orderlies.  The  work  is  exceed- 
ingly trying,  and  it  must  be  reckoned  on  that  not  a  few  of  the 
staff  will  be  more  or  less  knocked  up  after  three  or  four  weeks 
of  it.  But  it  is  also  quite  certain  that  the  early  and  thorough 
treatment  of  a  very  large  proportion  of  all  wounds  has  done 
more  than  anything  else  to  save  much  suffering  and  many  lives. 

Advanced  Operating  Centers. — It  has  sometimes  been  found 
that  difficulties  of  locality  have  prevented  the  placing  of  so  large 
a  unit  as  a  casualty  clearing  station  exactly  where  its  position 
should  have  been  when  heavy  fighting  has  been  expected,  and 
in  such  cases  a  smaller  unit  has  been  placed  so  as  to  deal  with 
the  most  urgent  cases,  and  especially  with  those  which  required 
prompt  operation.  These  special  hospitals  of  fifty  to  sixty  beds 
have  done  excellent  work,  and  a  very  large  proportion  of  their 
cases  have  been  abdominal  wounds.  The  large  number  of  the 
casualty  clearing  stations  has  prevented  any  necessity  for  cre- 
ating many  such  units. 

Special  Hospitals. — Special  hospitals  have  been  established  for 
the  care  of  head  cases,  shell  shock,  and  diseases  of  the  skin,  in 
addition  to  a  few  sanitary  hospitals  at  the  front. 

X-Rays. — At  the  beginning  of  the  war  x-rays  were  not  sup- 
plied at  the  front,  but,  coincidentally  with  the  development  of 
operating  work  in  the  casualty  clearing  stations,  the  need  of 
these  became  apparent.  At  first  mobile  x-rays  vans  were  sup- 
plied, but,  as  demands  for  these  increased,  it  became  necessary 
to  supply  stationary  plants  as  well,  more  especially  to  those 
casualty  clearing  stations  to  whose  share  it  fell  to  do  most  of 
the  operations;  and,  not  only  have  x-rays  been  of  great  service 
in  guiding  the  operator,  but  in  many  of  the  abdominal  wounds 
where  the  missile  has  been  retained  they  have  been  of  the  great- 
est service  to  the  surgeon  in  deciding  whether  operation  should  be 
done  at  all.  The  x-ray  plant  has  become  an  essential  for  the  work 
of  the  casualty  clearing  stations. 

Anesthetics. — At  the  beginning  of  the  war  chloroform  was  in 
general  use,  but  it  was  evident  that  there  were  many  objections 
to  its  universal  application,  and  other  agents  were  soon  employed 
as  well. 

Ether  has  been  largely  used,  and  was  formerly  administered 
by  the  open  method,  but  experience  has  shown  that  it  is  often 
inadvisable  to  use  it  thus  because  of  its  tendency  to  irritate  the 
air  passages.  For  at  least  six  months  of  the  year  the  men  who 
are  exposed  to  the  wet  and  cold  in  the  trench  area  are  suffering 
in  very  large  numbers  from  catarrhs  of  varying  degrees  of  se- 


ABSTRACTS  OP  WAR  SURGERY  25 

verity,  and  in  many  of  them  these  are  accentuated  by  the  fur- 
ther exposure  which  follows,  especially  when  a  man  falls  or  lies 
in  mud  or  water.  The  result  is  that  the  administration  of  any 
anesthetic  commonly  sets  up  so  much  bronchial  irritation  that 
the  patient's  life  is  endangered  by  an  attack  of  bronchitis  or 
bronchopneumonia.  These  complications  are  specially  danger- 
ous in  cases  of  abdominal  wounds  where  abdominal  respiration 
is  difficult  and  where  coughing  up  of  mucus  is  often  impossible 
because  of  pain  or  intestinal  distention.  It  is  indeed  a  fact  that 
a  very  large  proportion  of  all  the  deaths  following  abdominal 
wounds  and  operations  are  due  to  lung  complications,  and  these 
injuries  are  at  least  twice  as  fatal  in  the  winter  as  in  the  summer. 

Dr.  Shipway's  apparatus  for  the  administration  of  warm  ether 
vapor  has  been  of  the  greatest  value  under  those  circumstances, 
and  it  is  in  common  use  in  all  the  clearing  stations. 

Use  of  Antiseptics. — It  may  be  stated  in  general  terms  that  it 
is  the  custom  at  the  front  to  use  antiseptics  in  the  treatment  of 
wounds,  both  at  the  field  ambulances  and  the  casualty  clear- 
ing stations.  No  attempt  is  made  to  use  antiseptic  agents  to 
disinfect  the  wounds  on  the  field  at  the  time  of  injury,  for  all 
who  know  the  character  of  the  wounds  and  the  conditions  of 
the  wounded  men,  are  agreed  as  to  the  complete  futility  of  all 
such  efforts,  even  if  this  had  not  been  completely  demonstrated 
during  this  war.  But  experience  has  also  shown  that  in  France 
and  Belgium  the  wounds  are  so  heavily  infected  from  the  soil  that 
it  is  most  necessary  in  all  but  the  smallest  wounds  to  excise  very 
freely  all  the  exposed  and  torn  tissues  which  have  been  killed  or 
else  partially  devitalized  by  the  injury,  and  which  are  ingrained 
with  dirt  or  portions  of  clothing.  If  this  treatment  is  not  carried 
out  very  thoroughly  and  carefully,  and  if  free  drainage  is  not 
secured,  the  gravest  forms  of  sepsis  may  commence  in  serious 
wounds  in  a  very  few  hours.  It  is  common  experience  that  if  a 
badly  wounded  man  can  not  be  rescued  and  brought  into  the  field 
ambulance  until  after  the  lapse  of  twenty-four  or  thirty-six  hours, 
the  wound  is  often  already  so  badly  infected  and  the  patient 
himself  is  in  so  toxic  a  state  that  surgical  treatment  has  but  little 
chance.  It  may  be  said  truly  that  the  most  important  alteration 
in  treatment  since  the  early  days  of  the  war  is  that  excision  of 
damaged  tissue  has  become  the  routine  method  and  that  the 
earlier  it  is  carried  out  the  more  likely  it  is  to  be  successful. 

"EusoV  and  "Dakin's  Fluid." — Very  many  antiseptic  agents 
have  been  employed,  and  there  is  naturally  some  diversity  of 
opinion  as  to  which  is  the  best.     There  is  no  doubt,  however, 


26  ABSTRACTS  OF  WAR  SURGERY 

that  at  the  present  time  hypochlorous  acid  in  the  form  known  as 
"eusol,"  or  the  hypochlorite  of  soda  in  the  solution  known  as 
"Dakin's  fluid,"  are  more  extensively  used  than  any  others. 
The  method  of  Dr.  Carrel  has  been  increasingly  employed  for  the 
past  year,  and  wounds  treated  in  this  way  have  done  exception- 
ally well,  although  it  is  not  always  possible  to  employ  the  method 
universally  at  a  time  when  the  wounded  are  in  very  great  num- 
bers. At  other  times  there  is  no  difficulty,  and  in  order  to  estab- 
lish continuity  of  treatment  Dr.  Carrel's  method  is  freely  em- 
ployed on  every  ambulance  train  taking  wounded  to  the  base 
hospitals. 

Hydrogen  Peroxide. — This  is  not  highly  esteemed  as  a  potent 
antiseptic,  but  it  is  of  great  service  in  loosening  adherent  dress- 
ings. 

Carbolic  Acid. — At  an  early  stage  of  the  war,  and  in  consequence 
of  representations  made  by  surgeons  in  England,  attempts  were 
made  to  sterilize  recent  wounds  by  pure  carbolic  acid.  They 
entirely  failed  to  achieve  this  object,  but  solutions  of  a  strength 
of  1  in  20  or  1  in  40  are  in  common  use,  and  many  surgeons  have 
had  a  very  favorable  experience  in  using  equal  parts  of  solutions 
of  carbolic  acid  and  hydrogen  peroxide. 

Sodium  Chloride. — The  hypertonic  salt  solution  has  not  proved 
successful  at  the  front,  and  at  the  present  time  is  hardly  used 
at  all.  The  wounds  treated  by  it  were  usually  very  slow  in 
healing,  and  the  granulations  were  generally  pale,  flabby,  and 
much  overgrown.  There  has  also  been  a  good  deal  of  evidence 
to  show  that  secondary  hemorrhage  is  not  nearly  so  frequent 
an  occurrence  since  hypertonic  saline  has  been  displaced  by  other 
antiseptics.  This  is  not  at  all  surprising  when  it  is  considered 
that  rapid  cicatrization  is  the  best  safeguard  against  this  com- 
plication. 

The  salt  pack  largely  used  at  Rouen  is  also  to  a  great  extent 
supplanted  by  the  employment  of  "eusol"  and  "Dakin's  fluid." 
It  is,  however,  at  the  front  a  useful  method  of  treatment  of  large 
open  wounds  in  patients  who  are  in  transit  by  train.  It  does  not 
need  to  be  disturbed  for  several  days,  and  when  there  are  large 
numbers  of  wounded  to  dress  this  is  a  very  great  advantage. 

"B.I.  P." — The  mixture  of  bismuth  subnitrate,  iodoform,  and 
paraffin,  recommended  by  Professor  Rutherford  Morison  for  sup- 
purating wounds  ("B.  I.  P."),  has  also  been  used  for  the  past  few 
months  on  recent  wounds  of  the  soft  tissues,  and  also  in  cases  of  frac- 
ture. The  results  have  been  good,  and  encourage  the  further  use  of 
this  remedy  at  the  front.     The  fact  that  the  wounds  do  not  need 


ABSTRACTS  OF  WAR  SURGERY  27 

dressing  for  several  days  gives  it  the  same  advantage  as  the  salt 
pack,  while  its  use  permits  of  an  early  closure  of  the  wound, 
which  is  an  additional  advantage. 

Shock,  and  the  Condition  of  Wounded  Men. — The  condition  of 
wounded  men  necessarily  differs  as  wounds  are  more  or  less  se- 
vere, but  in  even  slightly  wounded  men  there  may  have  been 
much  bleeding,  exposure  to  cold,  want  of  sleep,  or  want  of  food. 
If  to  these  are  added  severe  pain  and  the  exhaustion  due  to  a 
hazardous  journey  over  broken  roads,  it  is  easy  to  appreciate 
that  very  many  patients  arrive  in  a  state  bordering  on  collapse. 
Experience  has  shown,  as  a  result  of  knowledge  of  these  condi- 
tions, that  it  is  not  possible  to  estimate  accurately  the  real  con- 
dition of  the  patient  until  he  has  been  rested  and  warmed,  and 
has  taken  food ;  and  especially  in  winter  time  the  most  important 
of  these  remedial  measures  is  undoubtedly  warmth.  This  may 
be  applied  by  warm  blankets  after  the  removal  of  wet  clothes, 
or  by  hot  bottles.  But  in  more  severe  cases  we  employ  a  "  light 
bath"  of  electric  lamps  beneath  a  cradle,  or  else  a  "hot-air  bath" 
extemporized  by  leading  under  the  bed  clothes  a  pipe  connected 
with  a  Primus  stove.  Hot  liquid  food  is  good  if  the  patient  can 
take  it,  but  he  is  often  nauseated  or  actually  sick  in  the  worst 
cases  of  shock,  and  then  small  enemata  with  brandy  are  very 
useful.  "Warmth  and  rest  are,  however,  of  more  importance  than 
nourishment,  and  if  the  patient  goes  to  sleep,  as  he  very  often 
does,  it  is  best  to  leave  him  undisturbed  for  some  time. 

Primary  Amputations. — Unless  a  man  is  bleeding  it  is  usual  to 
treat  him,  as  has  just  been  described,  before  any  operation  is 
performed,  but  it  is  often  necessary  to  postpone  amputation  for 
as  long  as  a  day,  or  even  two  days,  if  the  removal  of  the  limb 
is  to  be  done  at  the  thigh.  Many  men  will  survive  if  they  are 
allowed  sufficient  time  to  get  completely  over  the  shock  of  the 
injury,  who  would  certainly  die  if  subjected  to  immediate  opera- 
tion. 

It  is,  of  course,  evident  that  delay  in  removing  a  badly  smashed 
limb  may  result  in  dangerous  sepsis,  and  there  is  no  doubt  that 
the  threat  of  gas  gangrene  may  necessitate  operation  earlier  than 
might  be  wished.  Much  must  therefore  of  necessity  be  left  to 
the  discretion  of  the  surgeon  in  each  case. 

When  the  condition  of  the  limb  and  of  the  patient  permit,  a 
primary  amputation  should  be  performed  by  one  of  the  recog- 
nized methods  practised  in  the  usual  circumstances  of  civilian 
surgery,  suitable  flaps  being  provided.  It  is,  however,  never 
right  to  neglect  drainage  of  the  stump,  and  this  should  always 


28  ABSTRACTS  OF  WAR  SURGERY 

be  secured  by  the  use  of  a  large  drainage  tube,  at  any  rate  for  a 
period  sufficient  to  ensure  that  no  serious  sepsis  exists. 

The  seat  of  amputation  has  been  much  discussed,  but  in  our 
experience  the  best  general  rule  is  that  as  much  of  the  limb  as 
possible  should  be  saved,  quite  regardless  of  the  typical  "seat 
of  election"  as  prescribed  in  former  years;  primary  amputations 
through  joints  are,  however,  as  a  rule  to  be  avoided. 

Not  more  than  ten  minutes  need  be  spent  on  certain  grave 
emergency  amputations  and,  if  conducted  under  the  influence  of 
gas  and  oxygen  anesthesia,  many  apparently  hopeless  cases  can 
be  saved,  for  there  is  very  much  less  shock  than  would  be  en- 
tailed by  either  a  longer  operation  or  by  cutting  through  healthy 
and  sensitive  skin  and  muscle  higher  up  the  limb.  In  such  a  case 
the  making  of  a  suitable  stump  must  be  left  to  a  future  time. 

In  another  class  of  cases  the  leg  or  the  forearm  may  be  smashed 
beyond  recovery,  while  the  thigh  or  the  upper  arm  is  the  seat  of 
other  severe  wounds  complicated  by  the  presence  of  mud,  of 
portions  of  shell,  or  of  clothing.  It  is  quite  unwise  in  such  a 
case  to  amputate  high  up  the  limb,  and  it  is  best  to  perform  a 
"flush  amputation"  close  above  the  fracture,  and  again  leave 
to  the  future  the  formation  of  a  useful  stump  at  a  time  when 
the  damaged  tissues  have  recovered.  If  this  is  not  done,  not  only 
is  the  patient  exposed  to  more  severe  shock  by  a  high  amputation, 
but  his  stump  may  slough  and  a  yet  higher  up  removal  may  be 
necessary  if  he  ultimately  does  survive. 

Wound  Infections. — It  is  well  known  that  in  France  wounds 
are  liable  to  be  very  heavily  infected  by  numerous  pathogenic 
organisms,  and  inquiry  from  surgeons  who  have  had  experience 
in  other  theaters  of  warfare  enables  us  to  say  that,  especially 
in  Egypt  and  in  the  Dardanelles,  gas  gangrene  and  tetanus 
infections  were  notably  much  less  common  than  they  are  in 
France. 

While  no  time  of  year  or  condition  of  weather  brings  immunity, 
it  is  very  evident  that  wet  weather  and  mud  are  far  more  dan- 
gerous than  summer  weather  and  dust ;  and  this  danger  is  much 
increased  when  patients  are  wounded  in  very  cold  weather  and 
are  thoroughly  chilled  before  they  can  be  brought  in.  Most 
surgeons  are  also  agreed  that  the  coldness  and  lowering  of  vi- 
tality caused  by  severe  hemorrhage  have  a  similar  predisposing 
effect  on  microbic  infection,  and  it  will  be  found  that  wounded 
men  are  attacked  by  tetanus  and  gas  gangrene  in  proportion  as 
the  various  conditions  exist  which  are  inimical  to  the  human 
organism.     It  has  also  been  noted  that  gas  gangrene  has  often 


ABSTRACTS  OF  WAR  SURGERY  29 

affected  wounds  in  patients  who  have  subsequently  developed 
tetanus  also. 

Gas  Gangrene. — This  disease  appeared  very  early  in  the  war 
and  was  a  very  unpleasant  surprise  to  the  surgeons.  It  had  not 
been  described  as  a  usual  complication  of  gunshot  wounds,  and 
though  seen  occasionally  in  civil  life,  so  that  its  etiology  was 
known  to  a  certain  extent,  it  was  sufficiently  unfamiliar  to  render 
an  accumulation  of  experience  necessary  for  its  proper  treatment. 

Two  clinical  types  of  the  disease  were  recognized  early  and 
were  named  "gaseous  cellulitis"  and  "massive  gas  gangrene." 
The  former  term  was  applied  to  the  milder  cases  in  which  the 
cellular  tissue  round  the  wound  was  considered  to  be  the  primary 
seat  of  the  disease;  the  latter  term  to  those  cases  in  which  the 
whole  limb  was  rapidly  affected  and  died.  The  milder  type  of  the 
disease  was  treated  by  incisions  and  drainage,  the  severer  type 
by  amputation. 

From  a  clinical  point  of  view  it  was  found  that  the  conditions 
that  favored  the  onset  of  the  disease  were :  (a)  The  retention  of 
extravasated  blood  and  wound  secretions,  (b)  interference  with 
the  circulation,  (c)  the  presence  of  large  masses  of  partially 
devitalized  or  dead  tissues,  (d)  extensive  comminution  of  long 
bones,  (e)  the  presence  of  particles  of  clothing  in  the  depth  of 
the  wound. 

(a)  The  avoidance  of  the  retention  of  blood  and  secretions 
necessitated  the  employment  of  some  sort  of  dressing  that  would 
not  dry  and  cake  during  the  transit  of  the  patient  to  the  casualty 
clearing  station  and  from  there  to  the  base.  It  did  not  seem  to 
matter  what  chemical  was  used  so  long  as  the  dressing  remained 
moist. 

(b)  Interference  with  the  circulation  was  brought  about  in 
several  ways.  First  there  was  the  tourniquet.  Every  effort  was 
made  to  dispense  with  this  instrument,  and  where  this  was  not 
possible  the  patient  was  taken  with  all  celerity  to  the  nearest 
place  where  the  hemorrhage  could  be  stopped.  Circular  band- 
ages were  found  also  to  be  a  source  of  trouble. 

In  simple  flesh  wounds  it  was  easy  to  arrange  that  the  band- 
ages and  dressings  should  be  loosely  applied,  but  in  the  case  of 
fractured  lower  limbs  it  was  necessary  to  obtain  some  fixation 
of  the  limb,  for  the  movement  of  the  bones  was  not  only  painful 
to  the  patient,  but  calculated  to  produce  further  damage  to  the 
soft  parts.  The  adoption  of  the  Thomas  splint  largely  solved 
this  part  of  the  problem,  but  there  were  and  still  are  difficulties 
in  the  way  of  its  adoption  as  far  forward  as  is  desired.     Some 


30  ABSTRACTS  OF  WAR  SURGERY 

fractured  lower  limbs  are  still  sent  to  the  casualty  stations  with 
the  old  Liston  splint;  the  rapid  evacuation  of  all  wounded  that 
now  pertains  has,  however,  lessened  considerably  the  disadvan- 
tages of  this  splint. 

The  arrest  of  the  blood  supply  to  a  segment  of  a  limb  by  the 
rupture  or  thrombosis  of  an  artery  has  so  far  baffled  the  surgeon. 
Attempts  were  made  by  suture  and  the  employment  of  Tuffier's 
tube  to  restore  the  circulation ;  but,  so  far,  have  not  met  with  the 
success  that  was  hoped.  All  that  can  be  done  is  to  favor  the 
collateral  circulation  in  every  way. 

(c)  The  devitalized  tissue  that  formed  a  nidus  for  the  devel- 
opment of  the  gas-producing  organism  was  got  rid  of  by  excision 
through  the  opened  wound,  and  as  the  attention  paid  to  this 
mechanical  cleaning  of  the  wound  became  greater  so  did  the 
results  improve. 

While  surgeons  were  working  out  the  best  methods  of  treat- 
ment the  bacteriologists  were  studying  organisms  found  in  the 
wounds.  Many  bacteria  were  found,  but  the  blame  could  not  be 
definitely  fixed  on  any  one  organism,  and  in  many  cases  there 
was  a  mixed  infection.  The  Bacillus  aerogenes  capsulatus  of 
Welch  was  found  present  in  the  greater  number  of  cases.  The 
interesting  and  important  observation  was,  however,  made  that 
the  numbers  of  gas-producing  organisms  steadily  decreased  with 
the  lapse  of  time,  whilst  the  pus-producing  organisms  increased. 
This  bacteriological  fact  corresponded  with  the  clinical  observa- 
tion that  the  likelihood  of  gangrene  occurring  became  steadily 
less  as  the  wound  became  older  and  suppuration  more  obvious. 

A  later  abstract  gives  a  full  account  of  gas  gangrene  and  will 
supplement  the  remarks  made  by  Bowlby  and  Wallace  in  their 
paper  (see  p.  138  et  sequi). 

Abdominal  Wounds. — Surgical  Opinion  when  the  War  Started. 
— For  many  years  it  has  been  held  that  the  operative  treatment 
of  abdominal  wounds  was  not  to  be  advised  under  war  conditions. 
This  was  partly  due  to  want  of  success,  as  in  the  Spanish- Ameri- 
can War,  and  partly  to  the  fact  that  many  military  surgeons 
were  opposed  to  extensive  operating  anywhere  near  the  firing  line. 
Although  the  expectant  treatment  was  the  orthodox  one  when 
the  South  African  War  broke  out,  many  surgeons  at  that  time 
hoped  to  prove  that  it  was  wrong.  Surgeon-General  W.  F.  Ste- 
venson even  issued  an  appeal  for  the  trial  of  operation.  The 
result  was,  however,  only  to  confirm  former  opinion,  though  this 
opinion  was  now  held  on  two  somewhat  different  grounds.  One 
school  held  that  the  expectant  treatment  was  in  itself  the  right 


ABSTRACTS  OF  WAR  SURGERY  31 

procedure,  the  other  that  it  was  the  best  that  could  be  done  in 
war.  Some  believed  that  wounded  intestine  healed  sufficiently 
often  to  warrant  abstention,  others  believed  that  small  gut  lesions 
were  practically  always  fatal,  and  that  the  success  obtained  by 
the  "wait  and  see"  policy  was  due  to  the  escape  of  the  bowel 
from  injury,  although  the  belly  had  been  penetrated.  A  study 
of  the  literature  of  the  South  African  War,  both  private  and 
official,  makes  the  real  reason  for  want  of  success  in  operating  at 
once  obvious — the  cases  arrived  too  late.  It  was  not  so  much  a 
question  of  the  expectant  treatment  as  failure  of  the  operation. 

The  reason  for  the  late  operation  was  the  nature  of  fighting  in 
an  unsettled  country  of  great  distances.  The  wounded  could  not 
be  quickly  brought  to  a  hospital  with  the  necessary  appliances. 
To  operate  in  the  field  with  what  appliances  were  at  hand  was 
too  disheartening.  It  was  impossible  to  get  even  moderately 
good  conditions.  There  was  little  or  no  water,  and  what  there 
was  was  often  too  filthy  for  words — the  water  of  dams.  In 
addition,  there  was  the  plague  of  flies  that  settled  on  everything. 

The  conditions  were  utterly  different  from  those  that  pertain 
at  the  present  time.  This  is  the  first  time  since  the  rise  of  ab- 
dominal surgery  that  a  great  campaign  has  been  fought  in  a 
settled  country,  and,  what  is  more  important  still,  with  a  fixed 
fighting  line. 

In  this  present  war  one  of  the  difficulties  of  establishing  the 
operative  treatment  was  the  run  of  bad  luck  which  any  operator 
might  have  to  face.  Even  now,  with  conditions  as  nearly  ideal  as 
possible,  a  series  of  nine  consecutive  fatal  cases  may  be  met  with. 
This  must  have  a  very  depressing  effect  on  any  surgeon,  especially 
on  one  who  is  not  yet  convinced  that  the  operative  treatment 
is  in  the  main  the  best  of  all.  Now  nine  abdominal  cases  means 
roughly  about  600  wounded  men,  taking  a  moderate  estimate  of 
the  proportion  of  abdominal  wounds  to  total  wounds. 

As  a  matter  of  fact,  in  the  South  African  campaign  a  casualty 
list  of  600  wounded  was  considered  a  large  one,  and  if  an  operator 
happened  to  encounter  such  a  series  of  fatalities,  it  is  not  a  mat- 
ter of  surprise  that  he  should  have  had  doubts  as  to  the  correct- 
ness of  his  procedure. 

Statistics  in  the  present  campaign  show  that  an  operative  mor- 
tality of  50  per  cent  is  a  good  result,  but  such  a  mortality  in  civil 
practice  would  be  considered  an  awful  death-rate  to  face.  And 
yet  it  means,  looking  on  the  bright  side,  many  lives  saved. 

The  South  African  campaign  may,  then,  be  said  to  have  left 
surgical  opinion  opposed  to  operation,  but  it  must  always  be 


32  ABSTRACTS  OF  WAR  SURGERY 

remembered  that  not  only  were  there  practically  no  shell  wounds 
in  that  campaign,  but  also  that  the  ogival  bullet  was  a  much  less 
harmful  missile  than  the  sharp-pointed  bullets  of  the  present  war. 

Method  of  Treatment  in  the  Earlier  Period  of  the  War. — In  the 
retreat  from  Mons  and  on  the  Aisne  adequate  provisions  for  the 
performance  of  abdominal  operations  near  the  front  was  well- 
nigh  an  impossibility,  and  all  that  could  be  done  was  to  send, 
the  wounded  to  the  base  with  the  least  possible  discomfort  to 
them.  When,  in  the  ensuing  winter,  the  line  became  fixed  the 
circumstances  were  very  different,  and  there  soon  developed  a 
possibility  of  operating  under  good  conditions.  It  was  no  longer 
a  question  of  whether  a  man  could  be  operated  upon,  but  whether 
he  should  be  operated  upon.  Still,  however,  a  good  deal  of  the 
old  belief  in  the  efficacy  of  the  expectant  treatment  obtained 
for  some  time  longer.  A  man  wounded  in  the  abdomen  was 
sometimes  kept  in  a  dug-out  in  the  trench  system;  often  he  was 
kept  at  a  field  ambulance,  usually  he  was  transferred  to  the 
casualty  clearing  station  and  there  treated. 

The  customary  mode  of  procedure  was  to  put  the  man  in  the 
Fowler  position,  to  improve  the  general  condition  by  rest  and 
warmth,  to  withhold  food  and  water  for  three  days  and  to  ad- 
minister morphine.  The  thirst,  which  was  a  distressing  symptom 
of  this  treatment,  was  combated  to  a  certain  degree  by  rectal 
salines  and  mouth  washes. 

A  tribute  must  here  be  paid  to  the  great  care  and  attention 
which  the  medical  officers  lavished  on  the  patients.  If  anything 
could  have  got  these  men  well  the  attention  that  they  received 
would  have  done  so,  and  it  must  be  remembered  that  the  medical 
officers  who  conducted  the  treatment  were  convinced  of  its  ef- 
ficacy. This  belief  was  strengthened  by  the  behavior  of  many  of 
the  patients,  for  some  who  were  at  first  gravely  ill,  went  through 
a  period  of  improvement  which  often  was  very  striking.  There 
is  no  doubt  that  improvement  did  take  place,  and  so  well  were 
many  of  them  that  after  several  days  they  were  evacuated  to 
the  base  and  arrived  there  sometimes  in  fair  condition,  although 
more  often  gravely  ill.  But  the  surgeons  who  had  seen  the  cases 
leave  the  casualty  clearing  stations  apparently  on  the  way  to  re- 
covery could  not  at  first  bring  themselves  to  believe  that  they 
did  badly  at  the  base,  and  if  evacuation  had  not  been  necessary 
and  it  had  been  possible  to  keep  patients  at  the  casualty  clearing 
stations  the  expectant  treatment  would  not  have  survived  as 
long  as  it  did,  for  medical  officers  would  have  seen  many  such 
cases  become  worse  and  worse,  and  in  the  end — die. 


ABSTRACTS    OF    WAR    SURGERY  33 

Commencement  of  the  Operative  Treatment. — Sumo  attempts  a1 
operation  had  been  made  as  early  as  November,  1914.  During 
the  winter  of  1914-15  operations  were  done  by  several  medical 
officers.  But  the  early  results  wore  undeniably  bad — so  bad  that 
most  people  abandoned  the  attempt,  and  the  reasons  for  failure 
were  no  doubt  both  the  late  arrival  of  the  patients  at  a  place 
where  an  operation  could  be  performed  and  the  want  of  knowl- 
edge which  later  on  was  acquired  by  experience  alone,  for  there 
was  no  literature  which  dealt  with  such  injuries  as  the  surgeons 
were  now  called  on  to  treat,  and  each  man  had  to  learn  the  best 
methods  for  himself. 

Owen  Richards  was  the  first  to  publish  results  of  operative 
treatment  in  the  British  Army.  His  first  operation  was  per- 
formed on  January  28,  1915,  and  the  first  successful  operation, 
that  of  a  resection  of  two  and  one-half  feet  of  the  small  intestines, 
was  performed  on  March  18,  1915,  thirty-six  hours  after  the 
injury  was  received. 

In  May,  1915,  an  inquiry  into  the  causes  of  death  after  ab- 
dominal wounds  established  the  following  facts : 

1.  That  the  injuries  were  as  a  rule  of  such  a  nature  that  re- 
covery must  be  a  very  rare  event. 

2.  That  hemorrhage  was  a  chief  cause  of  early  death. 

3.  That  bullets  produced  very  extensive  injuries. 

The  discovery  that  bullets  produced  extensive  gut  injuries  was 
also  of  great  importance,  as  much  stress  has  been  laid  on  the 
smallness  of  the  lesions  produced  by  the  modern  small-bore  bullet, 
and  the  expectation  of  spontaneous  recovery  of  gut  lesions  had 
been  based  on  the  quite  erroneous  assumption  that  such  projec- 
tiles were  comparatively  innocuous. 

The  reestablishment  of  the  fact  that  hemorrhage  was  the  chief 
cause  of  early  death  was  of  great  importance,  as  it  showed  that 
only  rapid  evacuation  afforded  any  hope  of  combating  such  a 
condition.  Arrangements  were  accordingly  made  to  insure  that 
all  patients  suffering  from  abdominal  wounds,  and  who  were  not 
too  ill  for  transport,  should  be  sent  by  special  motor  ambulances 
to  the  clearing  station  and  not  retained  in  the  field  ambulance. 
The  result  of  this  diffusion  of  more  accurate  knowledge  was  soon 
seen  in  the  much  earlier  arrival  of  patients.  The  consequences  of 
these  improvements  soon  became  apparent  in  the  saving  of  many 
lives,  and  the  operative  treatment,  now  that  it  was  placed  under 
favorable  conditions,  very  soon  won  for  itself  the  confidence  of 
the  medical  service,  and  quickly  became  universally  adopted. 

Where  to  Operate. — The  British  practice  has  been  to  operate 


&4  ABSTRACTS  OF  WAR  SURGERV 

a  short  distance  behind  the  line,  and  the  wisdom  of  this  has  been 
demonstrated.  Here  it  is  possible  to  operate  under  good  condi- 
tions and  to  nurse  the  patient  among  cheerful  surroundings  for 
a  week  or  more  subsequently. 

The  casualty  clearing  stations  have,  as  a  rule,  been  used  for 
this  purpose.  If  for  some  local  reason  it  has  not  been  possible 
to  put  one  sufficiently  far  forward  at  any  one  part  of  the  line,  a 
small  operating  center  has  been  opened  for  the  reception  of  ab- 
dominal and  other  urgent  cases. 

Possibility  of  Escape  of  Hollow  Organs  After  Penetration  of 
the  Abdomen.— A  certain  number  of  cases  of  rupture  of  a  hollow 
viscus  without  abdominal  penetration  have  occurred,  and  have 
made  it  advisable  to  explore  the  intestine  in  some  instances  even 
when  the  whole  thickness  of  the  abdominal  wall  was  not  pene- 
trated by  the  missile,  but  where  the  symptoms  have  pointed  to 
the  probability  of  a  lesion  of  one  of  the  hollow  viscera. 

General  Line  of  Treatment.— The  practice  is  now  to  operate 
on  all  cases  unless  there  is  some  reason  to  the  contrary,  and  to 
operate  on  principle  rather  than  on  the  indications  by  symptoms. 

The  cases  on  which  operation  has  been  found,  as  a  general  rule, 
to  be  inadvisable  may  be  divided  into  two  classes — (1)  those  in 
which  solid  organs  alone  are  wounded  and  in  which  there  are  no 
signs  of  continuing  hemorrhage,  and  (2)  cases  arriving  after 
thirty-six  hours. 

The  liver  furnishes  by  far  the  greater  number  of  cases  in  class 
(1).  This  organ  is  the  only  solid  organ  in  which  it  is  possible 
to  say  from  inspection  that  no  other  organ  is  wounded.  In  the 
other  solid  organs,  such  as  the  kidney  and  spleen,  the  likelihood 
of  hollow  visceral  injury  nearly  always  compels  exploration. 
Were  it  not  for  this  contingency,  the  solid  organs  would  require 
little  operative  attention. 

In  class  (2)  the  time  for  successful  interference  in  the  case  of 
hollow  viscera  has  as  a  rule  gone  by,  and  the  bleeding,  from 
whatever  source  it  came,  has  ceased  spontaneously. 

Before  operation  a  period  of  rest  has  found  favor  with  most 
people.  This  period  is  used  to  combat  shock,  for  which  purpose 
heat  in  various  forms  has  proved  by  far  the  most  efficient  means. 

When  the  missile  is  retained  the  position  of  the  projectile 
should  be  ascertained  by  an  x-ray  picture,  as  its  localization  will 
influence  the  site  of  the  exploratory  incision.  The  incision  should 
as  a  rule  be  placed  by  the  side  of  the  mid-line  and  should  be  of 
ample  length.  A  transverse  incision  is  much  favored  by  some  for 
exploring  wounds  which  traverse  one  side  only  of  the  body. 


ABSTRACTS  OF  WAR  SURGERY  35 

The  question  of  the  administration  of  saline  is  important.  The 
subcutaneous  injection  of  saline  has  found  favor  in  the  past,  hut 
it  is  coming  to  be  recognized  that  very  little  is  absorbed  in  a 
shocked  man,  and  that  this  method  presents  no  advantages  over 
its  administration  by  the  natural  orifices.  If  these  are  not  avail- 
able the  intravenous  method  should  be  used. 

Axioms  of  Operative  Procedure. — Celerity  is  of  great  im- 
portance. The  body  heat  must  be  preserved  in  every  way.  There 
should  be  the  least  possible  exposure  of  the  viscera,  and  the  in- 
testines should  be  kept  inside  the  abdomen  as  much  as  is  com- 
patible with  the  necessary  manipulation.  The  least  possible 
should  be  done.  All  the  intestine  should  be  examined.  Suture 
of  the  intestine  should  always  be  preferred  to  resection  unless 
the  latter  is  inevitable,  or  saves  time,  and  experience  has  shown 
that  a  single  continuous  suture,  applied  so  as  to  invert  the  peri- 
toneum, is  quite  sufficient  and  perfectly  secure.  Linen  thread  or 
thin  silk  are  both  preferable  to  catgut,  and  care  is  required  not 
to  draw  the  stitches  too  tight.  If  resection  is  unavoidable,  end- 
to-end  anastomosis  is  preferable  to  lateral  apposition  as  a  rule. 
Solid  organs  should  be  disturbed  as  little  as  possible,  unless  ves- 
sels have  been  opened.  Excision  of  spleen  and  kidney  should  be 
practised  with  great  reserve.  Through-and-through  wounds  of 
the  liver  are  best  left  alone,  but  if  the  x-rays  show  a  large  piece 
of  shell  or  bomb  in  an  accessible  position  it  should  be  removed, 
for  if  left  it  generally  causes  dangerous  sepsis  in  the  organ.  Ab- 
dominal drainage  is  most  probably  of  little  use  except  in  local 
lesions.    Artificial  ani  in  the  colon  are  to  be  avoided  if  possible. 

Wounds  of  Special  Organs. — Stomach. — Wounds  of  the  stomach, 
though  less  severe  than  those  of  the  small  and  large  intestine, 
have  proved  decidedly  more  dangerous  than  was  supposed.  The 
fatal  result  has  largely  been  caused  by  hemorrhage  and  shock 
and  by  complication  with  other  visceral  injury. 

Small  Intestine. — In  the  small  intestine  the  multiplicity  of  the 
lesions  and  hemorrhage  from  the  mesentery  have  been  the  chief 
causes  of  failure.  As  many  as  twenty  lesions  have  been  met  with. 
In  one  case  a  successful  result  followed  a  resection  of  six  feet  for 
twenty  perforations.  In  another  case  fourteen  lesions  were 
sutured  and  followed  by  recovery. 

Large  Intestine. — The  large  intestine  wounds  have  been  mostly 
fatal  from  sepsis  of  the  retroperitoneal  tissue  in  the  case  of  ascend- 
ing and  descending  colons  and  from  complicated  injuries  in  the  case 
of  the  transverse  colon. 


36  ABSTRACTS  OP  WAR  SURGERY 

Rectum. — The  rectum  proper  has  not  been  wounded  so  often  as 
would  be  expected,  but  has  a  high  mortality. 

Liver. — The  liver  shows  a  large  proportion  of  recovery  after 
operation,  but  many  patients  would  have  got  well  without  opera- 
tion. 

Spleen. — The  spleen  injuries  have  not  been  very  dangerous  except 
where  the  lesions  have  necessitated  excision,  and  the  same  may  be 
said  of  the  kidney. 

Bladder. — Intraperitoneal  wounds  of  the  bladder  show  a  mor- 
tality of  56  per  cent,  where  uncomplicated,  but  those  associated 
with  small  gut  injury  have  proved  exceedingly  dangerous. 

Causes  of  Failure. — Hemorrhage,  sepsis,  and  shock  have  been 
the  chief  causes  of  death. 

Sepsis. — Under  this  head  are  included  peritonitis,  retroperi- 
toneal sepsis,  and  wound  infection.  It  is  unnecessary  to  say  much 
about  peritonitis.  It  causes  death  in  the  same  way  as  seen  in  civil 
practice.  Many  attempts  have  been  made  to  combat  the  so-called 
obstructive  symptoms  by  enterostomies  and  short  circuits,  but  with 
little  if  any  success.  Retroperitoneal  sepsis,  accompanied  or  not  by 
gas  formation,  has  proved  a  great  source  of  mortality.  This  has 
been  obvious  in  the  case  of  the  colon  injuries. 

Shock. — It  is  very  difficult  to  trace  any  definite  relation  between 
the  amount  of  injury  and  the  amount  of  shock.  It  can  only  be  said 
that  multiple  injuries  produce,  as  a  rule,  much  shock.  A  severe 
intestinal  lesion  will  not  in  all  cases  prevent  a  man  from  complet- 
ing the  task  on  which  he  was  engaged  or  even  from  walking  one  or 
two  miles,  and  many  who  subsequently  die  arrive  at  the  hospitals 
in  good  condition.  The  pulse  rate  table  gives  some  indication  of  the 
patient's  condition.  Prolapse  of  the  small  gut  seems  to  cause  less 
disturbance  than  that  of  the  stomach  and  colon.  Hemorrhage  is 
by  far  the  most  frequent  cause  of  death,  and  as  it  is  nearly  always 
present,  it  is  difficult  to  determine  how  much  shock  is  due  to  this 
cause  and  how  much  to  the  accompanying  injury.  There  is  a  cer- 
tain amount  of  evidence  to  show  that  comparatively  slight  injuries 
of  both  kidneys  and  liver  will  cause  intense  collapse,  but  such  cases 
are  not  common.  Sepsis  of  the  retroperitoneal  tissue  without 
severe  injury  does  cause  the  most  intense  shock. 

It  is  very  difficult  to  compare  the  present  mortality  with  that 
of  the  preoperative  period.  The  whole  method  of  evacuation  has 
completely  changed.  The  operative  treatment  has  attracted  to  the 
casualty  clearing  stations  all  men  wounded  in  the  abdomen,  so  that 
those  who  would  have  died  in  dug-outs,  at  the  advanced  dressing 


ABSTRACTS  OF  WAR  SURGERY  37 

stations,  and  at  the  field  ambulances,  now  reach  an  operative 
center. 

Neglecting  the  more  forward  positions,  a  calculation  made  in  the 
preoperative  days  showed  that  the  mortality  at  field  ambulances 
and  clearing  stations  was  70  per  cent.  In  addition  there  were  the 
deaths  at  the  base,  which  raised  the  mortality  80  per  cent. 

There  would  therefore  seem  to  have  been  an  improvement  from 
15  to  20  per  cent. 

Wounds  of  the  Heart. — There  has  been  one  successful  suture 
of  a  heart  wound.  It  was  performed  by  Captain  John  Fraser. 
The  patient  nine  months  later  reported  his  health  as  excellent. 

Wounds  of  Blood  Vessels. — It  may  in  the  first  place  be  noted 
that  the  conception  of  many  surgeons  of  the  size  of  the  lumen 
and  of  the  thickness  of  the  wall  of  arteries  in  general  has  under- 
gone a  change  in  this  war,  and  it  has  often  been  remarked  by  med- 
ical officers  that  the  arteries  are  smaller  and  have  slighter  walls 
than  was  expected.  No  doubt  the  class  of  subjects  from  which  one 
gained  an  idea  of  the  size  of  the  normal  blood  vessels  is  so  different 
from  the  class  met  with  in  war  surgery  that  there  was  an  exag- 
gerated idea  both  of  the  size  of  the  artery  and  of  the  thickness  of 
its  walls  in  healthy  young  adults. 

Surgeons,  knowing  that  they  would  have  to  deal  with  healthy 
arteries,  hoped  that  many  opportunities  would  present  themselves 
from  arterial  suture,  but  unfortunately  the  opportunities  have 
been  few,  and  the  injuries  have  rarely  been  of  such  a  nature  as  to 
offer  any  prospect  of  success  or  even  of  trial  of  such  treatment. 
Lateral  suture  both  of  veins  and  arteries  has  been  done  in  a  fair 
number  of  cases,  and  in  two  instances  a  lateral  rent  in  the  vena 
cava  itself  has  been  closed,  although  the  only  successful  case  was 
one  in  which  the  sides  were  brought  together  by  artery  forceps  and 
not  by  suture.  The  opportunity  of  end-to-end  suture  of  arteries 
has  rarely  offered  itself  at  the  front,  and  as  far  as  the  writers 
know  has  only  been  even  temporarily  successful  in  one  case,  that 
of  a  bullet  wound  of  the  brachial  artery;  and  this  vessel  gave 
way  and  formed  an  aneurysm  some  three  weeks  later.  In  a  few 
cases  the  femoral  artery  has  been  sutured,  but  in  no  case  has  the 
operation  saved  both  the  limb  and  the  patient. 

Although  so  far  the  results  have  been  disappointing,  this  is 
not  a  matter  for  surprise  if  the  condition  of  the  wounded  vessels 
is  examined.  The  class  of  case  in  which  it  was  hoped  to  try  this 
method  at  the  front  was  that  of  open  wounds  such  as  are  gen- 
erally caused  by-  shell ;  but  unfortunately  the  wounds  of  the  ar- 
tery are  commonly  so  far  apart  that  it  is  found  that  they  can  not 


38  ABSTRACTS  OF  WAR  SURGERY 

be  brought  into  apposition  after  the  necessary  dissection  of 
the  vessel  has  been  done.  Even  in  the  popliteal  space,  where 
some  approximation  of  the  arterial  ends  can  be  obtained  by 
flexion  of  the  knee,  no  case  has  yet  occurred  in  which  arterior- 
rhaphy  has  seemed  feasible,  while  small  wounds  of  the  limbs 
or  neck  with  an  arterial  hematoma  seem  hardly  suitable  for  this 
method  of  treatment. 

It  was  under  these  circumstances  that  "Turner's  tubes"  offered 
some  hope  of  saving  limbs  from  gangrene  when  arterial  suture 
was  out  of  the  question.  They  have  been  employed  at  the  front 
on  many  occasions,  and  are,  it  is  believed,  well  worth  trying,  as, 
although  they  become  blocked  within  about  twenty-four  hours, 
they  have  appeared  to  tide  a  limb  over  this,  the  most  critical 
period  before  the  establishment  of  the  collateral  circulation.  It 
must  be  remembered  that  in  actual  practice  the  limb  below  the 
lesion  has  been  deprived  of  blood  for  some  time  before  the  op- 
portunity occurs  of  inserting  a  tube  and  reestablishing  the  cir- 
culation, and  it  may  be  that  this  period  of  starvation  produces 
changes  in  the  vessel  walls  that  favor  clotting. 

There  is  another  observation  which  may  have  a  bearing  on 
this  subject.  In  civil  practice,  after  the  interruption  of  the 
main  blood  supply  of  a  limb  and  the  consequent  occurrence  of 
gangrene  in  its  lower  part,  one  looks  for  and  sees  the  formation 
of  a  definite  line  of  demarcation.  But  in  the  present  campaign 
it  has  been  found  that  after  the  destruction  and  ligation  of  an 
artery  this  line  of  demarcation  fails  to  appear  in  the  majority 
of  cases,  and  the  seat  of  the  amputation  has  to  be  chosen  by 
noting  the  place  where  the  limb  becomes  cold  and  discolored,  on 
the  one  hand,  and,  on  the  other,  where  the  capillary  circulation 
is  still  active,  as  shown  by  the  return  of  the  skin  blush  after 
pressure.  No  doubt  the  primary  loss  of  blood  has  something  to 
do  with  the  frequency  of  gangrene  in  the  first  place,  and  in  the 
second  it  would  appear  that  the  nature  of  the  injury  so  upsets 
the  blood  supply  of  the  limb  that  the  collateral  circulation  is 
slow  in  being  reestablished,  and  that  sufficient  blood  does  not 
reach  the  part  to  bring  about  the  rapid  and  healthy  reaction 
that  is  necessary  for  the  formation  of  a  distinct  line  of  demar- 
cation. 

It  is  a  fact  at  once  curious  and  important  that  the  arrest  of 
the  blood  current  at  a  point  that  is  considered  a  favorable  one 
for  the  application  of  a  ligature  in  civil  practice  is  often  followed 
by  gangrene  when  that  arrest  is  caused  by  a  gunshot  wound.  It 
may  be  that  the  laceration  of  muscle  that  so  often  accompanies 


ABSTRACTS  OF  WAR  SURGERY  39 

such  injury  is  the  cause  to  a  certain  extent,  but  there  must  be 
other  factors  at  work,  as  gangrene  may  follow  even  a  small  per- 
forating wound.  Wounds  of  certain  arteries  stand  out  as 
especially  dangerous  to  the  vitality  of  the  limb,  notably  those 
of  the  popliteal  and  the  anterior  and  posterior  tibials. 

Injuries  of  Joints. — A  great  change  for  the  better  has  taken 
place  in  the  results  obtained  in  the  treatment  of  wounded  joints. 

Experience  was  chiefly  gained  on  the  knee-joint,  for  it  is  the 
joint  most  frequently  hit,  most  easy  of  inspection,  and  its  infec- 
tion is  followed  by  disastrous  consequences  more  often  than  in  the 
case  of  other  articulations. 

In  the  early  days  two  lines  of  treatment  were  followed.  The 
small  perforating  wounds  were  let  alone  and  allowed  to  heal, 
the  progress  of  the  joint  being  tested  by  aspirations  if  neces- 
sary. The  larger  wounds  with  escape  of  synovia  or  actual  laying 
open  of  the  synovial  sac  were  drained,  and  at  first  the  drains 
were  often  introduced  into  the  joint  cavity.  The  results  of  this 
treatment  were  undeniably  bad,  and  all  sorts  of  heroic  measures 
were  adopted  for  the  arrest  of  the  septic  processes  which  en- 
sued. But  continuous  irrigation  or  an  acute  flexion  of  a  widely 
opened  articulation  gave  equally  poor  results,  and  the  patient 
was  lucky  if  he  escaped  with  a  stiff  leg. 

The  first  improvement  was  the  abandonment  of  the  intra- 
articular drains.  The  next  was  the  excision  of  the  wound,  the 
removal  of  any  foreign  body,  the  flushing  of  the  joint,  and  in  some 
cases  the  closure  of  the  capsule  and  the  insertion  of  a  super- 
ficial drain. 

The  next  step  was  perhaps  a  bold  one.  As  soon  as  possible 
after  the  receipt  of  the  injury — that  is,  in  the  casualty  clearing 
station — the  wound  was  excised,  the  joint  opened,  cleaned,  and 
irrigated,  and  then  the  whole  wound  in  the  synovial  sac  and 
the  superficial  tissues  was  tightly  closed.  It  was  certainly  aston- 
ishing how  seldom  infection  followed  such  treatment,  even 
when  fragments  of  shell  or  pieces  of  clothing  had  been  removed 
from  the  joint ;  but  for  its  success  it  is  essential  that  the  incisions 
around  the  wound  edges  should  be  carried  quite  clear  of  all 
infected  tissue,  and  that  the  strictest  asepsis  is  assured. 

Now,  every  knee-joint  with  such  a  wound  is  given  the  chance 
of  healing  by  first  intention,  although  the  closure  of  the  joint 
defect  may  entail  the  performance  of  a  plastic  operation  to 
provide  an  adequate  cover  with  a  flap  of  synovial  membrane 
or  skin.     Even  if  some  infection  does  follow  the  closure  of  the 


40  ABSTRACTS  OF  WAR  SURGERY 

joint,  it  is  well  not  to  be  in  too  great  hurry  to  lay  the  articula- 
tion open,  for  a  certain  number  of  such  joints  do  settle  down 
and  provide  a  better  limb  than  if  submitted  to  more  active  treat- 
ment. 

When  the  joint  wound  is  complicated  with  fracture  of  bone 
it  may  still  be  possible  in  some  cases  to  close  it  with  success. 
In  cases  of  compound  fracture  of  the  patella  with  loss  of  sub- 
stance, partial  or  complete  removal  of  the  fragments,  and  the 
provision  of  a  skin  flap,  will  often  be  followed  by  primary 
healing. 

When  the  tibia  or  femur  are  involved  the  case  becomes  more 
serious.  Of  the  two  fractures  that  of  the  tibia  is  the  most  to  be 
feared. 

In  cases  of  only  partial  loss  of  the '  articular  surface  of  either 
the  tibia  or  femur,  and  also  in  linear  oblique  fractures  of  both 
bones  running  up  into  the  joint,  it  is  often  worth  while  to  try  to 
close  the  joint  and  to  obtain  primary  union. 

Where  there  is  much  comminution  of  bone,  however,  and  a 
dirty  wound  it  is  better  to  abandon  all  hope  of  saving  the  joint 
and  perform  a  limited  primary  excision.  After  such  an  opera- 
tion the  joint  surfaces  are  usually  kept  apart  by  extension  on 
a  suitable  splint,  and  Carrel 's  treatment  adopted  until  the  wound 
cleans,  when  the  bone  surfaces  may  be  allowed  to  come  into 
contact. 

The  knee  is  the  only  joint  in  the  body  in  which  penetration 
of  the  synovial  sac  is  at  all  commonly  seen  without  damage  to 
the  bony  constituents  of  the  articulation.  It  is  therefore  not 
common  to  have  the  opportunity  of  closing  other  joints,  but  the 
opportunity  should  be  taken  when  it  is  offered. 

More  often  the  surgeon  has  to  treat  a  greatly  disorganized 
articulation,  and  in  such  cases  a  primary  excision  is  most  prob- 
ably the  best  course,  especially  in  the  case  of  the  shoulder  and 
the  elbow. 

The  primary  treatment  of  wounded  joints  may  be  summarized 
as  follows : 

1.  Fixation  on  a  suitable  splint.  In  the  case  of  the  knee  this 
splint  should  be  one  of  the  varieties  of  the  "Thomas"  as  used 
for  fractured  thigh. 

2.  Beyond  this  treatment  nothing  more  is  required  in  simple 
perforating  wounds. 

3.  The  taking  of  any  x-ray  picture  in  cases  where  there  is  a 
possibility  of  the  retention  of  a  missile  or  of  fracture  of  the 
bones. 


ABSTRACTS  OF  WAR  SURGERY  41 

4.  The  excision  and  cleansing  of  the  damaged  tissues  and 
the  exploration  and  lavage  of  the  joint. 

5.  The  closure,  if  possible,  of  the  joint  cavity. 

Head  Injuries. — At  the  beginning  of  the  war  surgeons  called 
upon  to  treat  head  injuries  applied  the  ordinary  rules  of  civil 
practice  and  operated  on  them  at  once.  They  were  confirmed 
in  their  opinion  that  operation  was  right,  since,  apart  from  the 
mere  physical  defects,  many  patients  seemed  to  be  suffering  from 
compression. 

These  operations  were  done  both  at  casualty  clearing  stations 
and  field  ambulances,  but  the  best  method  of  operative  treatment 
was  as  yet  undeveloped.  Next,  it  was  noticed  at  the  base  that 
cases  which,  from  force  of  circumstances,  arrived  there  un- 
operated  upon,  did  better  than  those  operated  on  at  the  front. 
This  was  attributed  at  first  to  faulty  technic,  and  within  limits 
this  criticism  was  just,  as  the  right  operation  was  as  yet  unde- 
veloped, both  at  the  base  and  the  front. 

The  observation  was  next  made  that  if  patients  were  kept 
quiet  at  the  place  where  they  were  operated  upon  they  did  well, 
while  cases  operated  on  and  apparently  doing  well  were  reported 
to  have  arrived  in  bad  condition  at  the  base  when  evacuated 
early. 

It  thus  became  obvious  that  there  were  two  reasons  for  head 
cases  doing  badly:  (1)  The  want  of  a  good  operation,  (2)  early 
evacuation  of  cases  well  operated  on. 

There  were  then  two  alternatives :  The  cases  must  be  either 
operated  on  at  the  front  and  kept,  or  else  evacuated  as  soon  as 
possible  to  the  base  before  operation;  a  patient  must  not  be 
operated  upon  and  evacuated  forthwith.  Two  procedures  were 
therefore  adopted.  In  times  of  pressure  head  cases  were  cleaned 
up  and  sent  to  the  base  at  once,  provided  they  were  fit  to  travel, 
and  in  quiet  times  they  were  operated  on  and  kept  at  rest  at  a 
casualty  clearing  station  for  a  week  or  ten  days.  Even  this 
period  of  rest  after  operation  proved  too  short,  though  the  results 
were  better  than  in  earlier  evacuation. 

The  next  step  was  the  establishment  of  special  hospitals  for 
head  cases  at  the  front.  Advantage  was  taken  of  the  fact  that 
a  head  case  before  operation  travelled  well,  and  the  special  hos- 
pitals were  placed  in  the  back  part  of  an  army  area.  These  hos- 
pitals were  never  subjected  to  the  sudden  pressure  that  may  fall 
on  an  advanced  casualty  station,  and  consequently  the  cases  could 
remain  there  for  a  long  time.  By  this  means  patients  experi- 
enced the  advantages  both  of  early  operation  and  prolonged  rest. 


42  ABSTRACTS  OF  WAR  SURGERY 

If  the  pulse  is  slow  they  are  sent  on  to  the  special  hospital.  If 
the  pulse  is  rapid  they  are  put  to  bed  and  evacuated  later,  should 
they  improve.  No  special  attention  is  paid  to  the  type  of  wound 
— reliance  is  placed  on  the  slow  pulse  as  a  sign  that  the  patient 
will  bear  the  journey. 

The  type  of  operation  that  has  eventually  been  found  most 
beneficial  has  been  arrived  at  after  many  changes.  Workers, 
comparatively  far  apart  and  not  in  direct  communication,  have 
evolved  very  much  the  same  operation.  At  the  front  a  small 
conservative  operation  was  formerly  practised  which  experience 
has  shown  to  have  been  a  little  too  limited  in  scope.  At  the  base 
there  were  two  schools — one  favored  an  extensive  removal  of 
bone  and  a  scalp  flap,  the  other  an  enlargement  of  the  scalp 
wound  and  a  limited  removal  of  bone.  Gradually  the  types  of 
operations  have  approximated.  It  has  been  found  that  the 
removal  of  bone  sufficient  to  expose  half  an  inch  square  (1.27  cm.) 
of  uninjured  dura  is  best  suited  to  most  cases.  Opinions  still 
differ,  perhaps,  as  to  the  comparative  merits  of  making  a  flap 
or  enlarging  the  scalp  wound.  On  the  whole,  the  flap  is  the  best 
as  a  routine,  unless  the  wound,  as  in  the  case  of  a  horizontal 
one,  is  so  situated  as  to  compel  the  use  of  a  very  large  one. 

The  recognition  of  the  fact  that  a  slow  pulse  is  not  necessarily 
a  symptom  of  compression  (for  it  may  occur  with  a  wide  exposure 
of  the  brain),  and  that  the  symptoms,  paralytic  and  otherwise, 
are  not  due  to  depression  of  fragments  but  to  a  destruction  or 
commotion  of  the  brain  matter  which  is  not  remediable  by  opera- 
tion, has  also  had  an  effect  upon  procedure.  In  the  first  place, 
a  slow  pulse  is  welcomed  as  a  sign  that  recovery  may  follow, 
and  it  is  not  taken  as  a  sign  that  operation  is  urgently  needed, 
but  rather  that  it  is  worth  doing.  The  recognition  that  depression 
of  fragments  is  not  the  usual  cause  of  the  symptoms  has  also 
done  away  with  the  notion  that  their  removal  must  be  imme- 
diately undertaken. 

It  is  true,  that  the  sooner  a  dirty  wound  is  cleaned  up  the  bet- 
ter, but  immediate  operation  is  in  many  head  cases  followed  by  a 
great  drop  in  blood  pressure,  so  that  some  delay  may  be  actually 
beneficial  on  this  account,  and  Colonel  Sargent  has  pointed  out 
that  for  at  least  twenty-four  hours  after  injury  the  brain  is 
liable  to  be  edematous,  and  to  extrude  unduly  if  operated  on 
while  in  this  condition.  A  moderate  delay  has  also  been  said 
to  do  good  in  that  it  allows  adhesions  to  form  between  the  dura 
and  the  pia  mater,  thus  lessening  the  chance  of  a  spread  of  in- 
fection over  the  brain  surface. 


ABSTRACTS  OF  WAR  SURGERY  43 

At  the  same  time  that  the  best  type  of  operation  as  regards 
the  scalp  and  bony  defect  was  being  evolved  many  other  points 
were  in  the  process  of  settlement : 

1.  Excision  of  the  wound  was  soon  decided  on. 

2.  There  was  at  first  considerable  discussion  as  to  how  far 
the  brain  should  be  explored  for  bone  fragments  on  the  one  hand 
and  the  projectile  on  the  other.  Every  one  was  agreed  that  an 
x-ray  picture  had  become  a  necessity,  and  the  opinion  was  grad- 
ually formed  that  a  limited  and  intelligent  search  for  bony 
fragments  and  other  foreign  bodies  was  beneficial,  but  that 
attempts  to  reach  a  missile  which  was  deeply  embedded  in  the 
brain  was  not  justifiable.  Results  seem  to  have  proved  the  cor- 
rectness of  this  line  of  treatment,  for  fragments  of  shell  are 
reported  to  have  caused  little  trouble  provided  their  weight 
was  not  enough  to  cause  pressure  on  the  surrounding  brain 
during  movements  of  the  patient. 

3.  The  fact  that  many  patients  with  head  wounds  suffered 
from  septic  complications,  and  the  general  demand  for  the  drain- 
age of  all  wounds,  led  at  first  to  the  employment  of  drainage 
in  most  cases  of  cranial  surgery,  not  only  of  the  scalp  but  of  the 
brain  also.  The  results  of  drainage  of  the  brain  were  not  satis- 
factory, and  gradually  it  was  abandoned,  at  any  rate  as  a 
primary  measure.  The  introduction  of  tubes  was  first  omitted, 
and  subsequently,  systematic  attempts  were  made  to  cover  in 
the  exposed  brain,  the  scalp  being  brought  together  over  the 
defect  in  the  bone  and  dura,  either  by  simple  suture,  pericranial 
flaps,  or  relieving  incisions  formed  by  undercutting  the  scalp. 
A  drain  introduced  under  the  scalp  is  still  generally  employed. 
This  covering  up  of  the  brain  seems  to  have  been  a  decided  suc- 
cess, and,  although  septic  complications  are  still  too  often  met 
with,  they  are  less  frequent  than  in  former  times.  There  has 
consequently  been  a  great  decrease  in  the  number  of  cases  of 
hernia  cerebri. 

4.  There  is  still  some  difference  of  opinion  as  to  whether 
small  cranial  depressions  and  linear  fractures  with  slight  in- 
equality of  surface,  uncomplicated  by  symptoms,  should  be 
operated  on  in  the  first  instance. 

5.  Most  surgeons  have  accepted  the  recommendation  of  Sar- 
gent and  Gordon  Holmes  that  depressed  fractures  over  the  longi- 
tudinal sinuses  should  be  left  alone  in  the  first  instance. 

6.  Most  operators  are  of  the  opinion  that  the  dura  mater 
should  not  be  opened  if  found  intact.    The  recognition  that  true 


44  ABSTRACTS  OF  WAR  SURGERY 

compression  of  the  brain  is  seldom  seen  has  helped  the  forma- 
tion of  this  opinion. 

7.  A  general  anesthetic  may  with  advantage  be  replaced  by 
the  local  use  of  novocaine  and  adrenalin.  If  this  method  is 
adopted  the  patient  is  given  either  hyoscine  and  morphine  or 
omnopon  and  scopolamine  an  hour  before  the  operation. 

Fractures. — The  tendency  throughout  the  war  has  been  to 
abandon  all  constricting  splints  and  to  trust  to  extension  for 
fixation  of  fragments.  In  the  first  place,  a  bandage  round  a 
limb,  which  might  from  swelling  or  movement  cause  constric- 
tion, was  found  to  favor  the  onset  of  gas  gangrene,  and  in  the 
second,  the  various  forms  of  Thomas's  splint,  in  which  the  limb 
lies  on  a  cradle,  gained  more  and  more  reputation  as  a  means  of 
efficient  splintage.  Few  other  splints  are  now  used  on  the  lower 
extremity.  It  is  curious  that  while  plaster  splints,  both  as 
emergency  contrivances  and  as  a  means  of  permanent  fixation, 
have  steadily  increased  in  use  in  the  French  army,  in  our  own 
they  have  as  steadily  fallen  into  disuse. 

The  treatment  of  a  compound  fracture  must  be  divided  into 
two  parts:  (a)  The  cleansing  of  the  wound;  (b)  the  setting 
or  reduction  of  the  fracture,  followed  by  its  maintenance  in 
good  position.  In  the  early  stages  the  first  is  by  far  the  most 
important,  and  on  its  attainment  depends,  within  limits,  the 
success  of  the  second. 

Total  immediate  reduction  is  good  and  to  be  aimed  at,  pro- 
vided it  can  be  carried  out  without  prejudice  to  the  cleansing  of 
the  wound,  but  an  incomplete  reduction,  or  even  no  reduction  at 
all,  may  be  advantageous  by  aiding  the  disinfection  of  the 
wound.  Surgeons  working  at  the  front  are  therefore  mainly 
concerned  with  the  primary  cleaning  of  the  wound  and  with  the 
means  to  transport  a  patient  to  the  base  with  comfort  and  without 
detriment  to  the  wounded  limb. 

The  organisms  that  infect  a  compound  fracture  may  be  roughly 
divided  into  two  classes :  (a)  Anaerobic  or  gas  gangrene  pro- 
ducing infection;  (b)  infection  due  to  pus-producing  organisms. 

Anaerobic  or  gas  gangrene  producing  infections  affect  chiefly 
the  muscles,  is  sudden  in  onset  and  development,  but  tends  to 
die  out  if  not  fatal  in  the  early  stages. 

Infection  by  pus-producing  organisms  affects  all  the  structures 
of  a  limb,  is  generally  of  slower  development,  and  fatal  at  a 
considerably  later  period.  The  first  (a)  is  the  chief  cause  of 
death  at  the  front,  the  second  (b)  of  death  at  the  base. 

From  the  fact  that  it  affects  muscles,  the  first  is  more  amenable 


ABSTRACTS  OF  WAR  SURGERT  45 

to  treatment  by  mechanical  means — the  excision  of  the  affected 
part  or  part  likely  to  be  infected;  but  the  second  giving  little 
indication  of  its  presence,  can  not  be  so  easily  removed  by  such 
means. 

At  the  beginning  of  the  war  fractures  were  treated  very  much 
as  they  were  in  South  Africa.  It  is  true  that  fragments  of  pro- 
jectiles and  clothing  were  removed,  but  more  attention  was  paid 
to  the  solution  of  continuity  of  the  bones  than  to  the  cleansing 
of  the  wound. 

The  occurrence  of  gas  gangrene  quickly  called  for  a  remedy, 
which  was  found  in  amputation  or  incisions  into  the  limb.  Then 
came  the  demand  from  the  base  for  free  drainage.  At  first  small 
tubes  were  used;  as  these  proved  inefficacious,  large  tubes  were 
substituted.  At  the  same  time  came  a  more  systematic  search 
for  foreign  bodies.  This  produced  an  improvement,  and  it  was 
reported  that  the  cases  that  came  down  with  adequate  drainage, 
especially  those  with  dependent  drainage,  stood  a  far  better 
chance  than  those  in  whom  such  measures  were  not  taken. 

About  this  time,  attention  was  drawn  to  the  fact  that  many 
flesh  wounds,  if  freely  excised,  could  be  sutured  with  success. 
The  application  of  this  principle,  though  it  could  not  be  applied 
in  toto  to  fractures,  led  to  more  extensive  opening  up  and  to 
better  mechanical  cleaning  by  the  excision  of  all  dead  tissue  and 
the  more  efficient  removal  of  foreign  bodies.  These  measures 
greatly  reduced  the  occurrence  of  gas  gangrene  and  produced 
an  improvement  in  the  suppurative  infections.  At  the  same  time 
as  these  improvements  were  taking  place  in  operative  technic 
the  adoption  of  the  Thomas  splint  for  the  lower  extremity  in  one 
of  its  many  forms  was  steadily  working  its  own  good.  The 
stretcher  in  the  ambulance  car  and  the  cot  in  the  train  presented 
a  difficulty — there  was  nothing  on  which  to  rest  the  splint.  This 
difficulty  was  overcome  by  two  methods:  (1)  A  form  of  the 
Thomas  splint  provided  with  an  attached  foot-piece  or  prop  was 
used  so  that  the  splint  was  raised  off  the  stretcher  and  the  limb 
lay  slung,  as  it  should  be  in  the  splint.  (2)  Two  forms  of  iron 
bracket,  attached  to  the  foot  of  the  stretcher,  allowed  the 
Thomas  splint  to  be  suspended  above  the  canvas  of  the  stretcher. 

Patients  thus  travelled  easily  in  the  motor  ambulances,  and 
the  difficulty  of  the  cot  in  the  train  was  easily  surmounted  by 
sending  the  patient  down  on  the  stretcher.  This  latter  expedient 
has  been  of  great  benefit  to  the  wounded,  as  once  placed  on  his 
stretcher  at  the  casualty  clearing  station  he  can  remain  undis- 
turbed until  he  reaches  his  bed  at  the  base. 


46  ABSTRACTS  OF  WAR  SURGERY 

The  fixation  in  a  Thomas  splint  depends  upon  the  extension. 
An  efficient  extension  is  therefore  of  prime  importance.  Sinclair's 
glue  has  provided  the  means.  It  is  easily  and  quickly  applied, 
and  has  the  additional  advantage  that  it  produces  no  constric- 
tion of  the  limb.  It  has  another  advantage,  it  can  be  used  when 
only  a  short  portion  of  the  leg  is  available,  a  very  great  gain 
when  dealing  with  limbs  covered  with  multiple  wounds. 

There  are,  of  course,  a  few  fractures  of  the  femur  that  can  not 
be  treated  with  Thomas 's  splint — namely,  those  in  which  a  wound 
has  been  received  on  the  part  covered  by  the  ring.  For  these 
the  old  Liston  splint  is  used,  or  in  some  cases  the  abduction  frame 
of  Jones,  though  the  bulk  of  the  latter  makes  it  unsuitable  for 
work  at  the  front. 

Below  the  knee  the  Thomas  splint  can  nearly  always  be  used, 
except  in  those  cases  in  which  the  fracture  is  near  the  ankle. 
Even  here  it  is  often  possible  to  use  it  by  the  aid  of  the  sole 
extension  as  devised  by  Sinclair. 

In  the  case  of  fractures  of  the  upper  extremity  the  Thomas 
splint  has  not  proved  so  satisfactory,  but  only  for  the  reason 
that  the  straight  posture  of  the  arm  is  unsuited  to  transport 
except  under  special  circumstances,  as  in  transit  by  barge.  The 
form  of  Thomas  splint  for  the  bent  arm  has  not  proved  a  suc- 
cess. For  transport  the  form  of  internal  angular  splint,  with  a 
hinged  back  piece  for  the  upper  arm  as  devised  by  Captain  Colin 
Clarke,  is  probably  the  best. 

The  development  of  the  operative  side  of  the  casualty  clearing 
station  and  the  provision  of  x-rays  has  been  of  inestimable  benefit 
to  the  patient.  There  can  be  no  doubt  that  the  chance  of  the 
patient  recovering  with  a  good  limb  and  of  escaping  a  long  period 
of  suppuration  depends  on  the  attention  that  can  be  paid  to  his 
wound  in  the  first  instance.  No  amount  of  after-care  can  ever 
make  up  for  the  want  of  it  at  the  first  moment.  A  thorough  and 
deliberate  operation  is  all-important.  There  must  be  a  free 
opening;  the  cavity  must  be  explored  by  the  eye,  and  not  only 
by  the  finger,  otherwise  dead  tissue  and  possibly  foreign  bodies 
will  be  passed  over. 

When  first  received  the  wound  is  dirty,  but  the  number  of 
pus-producing  bacteria  is  comparatively  few.  In  a  few  days  it  is 
probable,  no  matter  what  treatment  is  advised,  that  they  will 
have  greatly  increased  in  number.  If  the  first  operation  has 
been  incomplete,  a  second  may  be  necessary  at  the  very  time  that 
the  wound  is  in  the  worst  possible  state,  and  the  procedure 
necessary   to   supplement   the   primary   operation  may   be   disas- 


ABSTRACTS  OF  WAR  SURGERY  47 

trous  in  exposing  fascial  planes  to  infection  from  a  wound  teem- 
ing with  bacteria. 

The  early,  deliberate  and  efficient  cleansing  of  the  wound  i.« 
the  basis  of  success,  no  matter  what  chemicals  are  used  after  it 
is  completed. 

DEVELOPMENT   OF   BRITISH   SURGERY  IN   THE   HOSPI- 
TALS ON  THE  LINES  OF  COMMUNICATION  IN  FRANCE. 

— Surgeon-General  Sir  George  H.  Makins.     Brit.  Med.  Jour., 
June  16,  1917. 

The  general  hospitals  on  the  lines  of  communication  in  France 
have  undergone  a  steady  process  of  extension  in  accommodation 
and  development  since  August,  1914.  They  have  been  housed 
very  variously — some  in  the  original  tent  units,  some  in  huts, 
and  some  in  large  buildings  adapted  to  their  present  purpose. 
Tented  units  under  the  climatic  conditions  of  France  have  proved 
to  possess  but  one  virtue,  that  of  mobility,  and  in  all  the  tented 
hospitals  still  remaining  a  certain  proportion  of  huts  for  serious 
cases,  operating  theaters,  mess  accommodation,  stores  and  offices, 
have  been  added.  The  most  satisfactory  units  are  hutted 
throughout,  and  these  leave  little  to  be  desired  either  for  comfort 
or  for  satisfactory  work.  Most  of  the  buildings  now  in  use  are 
either  of  the  nature  of  public  buildings  or  of  large  hotels.  Each 
possesses  some  special  advantages.  The  large  rooms  of  casinos, 
etc.,  form  excellent  wards,  easily  overlooked  and  economical  to 
work,  but  such  buildings  need  usually  considerable  reinforcement 
with  regard  to  sanitary  accommodation.  The  hotels  are  more 
convenient  for  officers  as  providing  a  large  number  of  smaller 
rooms,  but  this  necessitates  a  somewhat  larger  nursing  staff, 
and  renders  attention  to  individual  patients  a  more  troublesome 
task. 

Special  hospitals  are  set  apart  for  the  treatment  of  infectious 
cases,  for  skin  diseases,  and  for  venereal  cases. 

Each  unit  is  complete  in  itself,  possessing  operating  theaters, 
clinical  laboratory,  and  its  own  disinfecting  apparatus.  The  only 
department  that  is  commonly  massed  when  a  number  of  units  are 
collected  in  the  same  area  is  the  mortuary  and  accommodation 
for  postmortem  examinations.  The  majority  of  the  units — the 
normal  capacity  of  which  is  520  beds — have  been  extended  by 
the  provision  of  additional  ward  accommodation  to  receive  1,040 
patients,  while  in  times  of  stress  a  further  extension  of  2,000  is 


48  ABSTRACTS  OF  WAR  SURGERY 

possible  by  the  addition  of  tents.  The  number  of  patients  that 
may  need  to  be  dealt  with  during  active  fighting  may  be  very 
large;  thus  during  the  first  three  months  of  the  action  on  the 
Somme  as  many  as  8,500  wounded  men  have  been  passed  through 
a  single  unit.  This  necessitates  ample  operating  theater  accom- 
modation, and  in  all  either  a  large  theater  is  provided,  or  in  one 
type  of  unit  two,  so  that  at  least  four  operating  tables  can  be 
kept  at  work  contemporaneously.  In  spite  of  these  provisions, 
at  busy  times  the  surgeons  may  be  engaged  continuously  in  shifts 
for  two  or  three  days  and  nights  without  cessation. 

Within  certain  limits,  arrangements  exist  for  the  aggregation 
of  special  classes  of  injury,  such  as  fractures  of  the  bones  of  the 
limbs,  injuries  to  the  face  and  jaws,  compound  and  complicated 
fractures  of  the  skull  and  vertebral  column,  and  wounds  of  the 
chest. 

Hospital  Trains  and  Motor  Ambulances. — The  vast  majority 
of  the  patients  admitted  to  the  general  hospitals  are  brought 
down  by  the  hospital  trains.  The  development  of  the  hospital 
train  in  France  was  a  matter  of  extreme  urgency  and  great  diffi- 
culty in  the  initial  stages  of  this  campaign.  It  seems  as  if  both 
France  and  Germany  had  relied  for  the  railway  transport  of  the 
wounded  on  the  same  means  which  served  the  purpose  in  the  war 
of  1870-71.  To  add  to  the  miseries  of  the  journeys  made  in  these 
trains,  they  were  long,  sometimes  extending  over  two  or  three 
days  before  the  west  coast  was  reached.  Odd  carriages  of  every 
build  and  description  were  obtained  whenever  opportunity 
offered,  and  within  a  few  weeks,  with  alterations  hastily  but 
effectively  carried  out,  a  number  of  efficient  if  not  luxuriously 
appointed   hospital   trains   were   forthcoming. 

One  word  should  be  added  regarding  the  fleet  of  improvised 
barges  which  run  on  the  canals  between  the  front  and  two  of  the 
general  hospital  areas.  There  is  no  doubt  that  the  smooth  passage 
of  these  boats  provides  the  acme  of  comfort  for  patients  to  whom 
the  unavoidable  shaking  of  a  railway  journey  entails  both  pain 
and  harm.  It  is  unfortunate  that  the  general  utility  of  the  barges 
is  limited  to  the  few  districts  in  which  canals  are  to  be  found. 

The  splendid  motor  ambulance  convoys  attached  to  each  dis- 
trict, and  for  most  of  which  the  army  is  indebted  to  the  Red 
Cross  Societies  of  the  United  Kingdom  and  the  Colonies,  have 
been  already  referred  to  as  to  their  work  at  the  front,  and  no 
further  mention  of  their  devoted  work  is  necessary  at  this  place. 

As  to  the  last  link  between  the  general  hospitals  on  the  lines 


ABSTRACTS  OF  WAR  SURGERY  49 

of  communication  and  the  base  in  England,  the  hospital  ships, 
it  suffices  to  say  that  they  leave  nothing  to  be  desired. 

Wound  Treatment. — This  question  has  abated  no  jot  of  its 
capacity  for  arousing  controversy  and  avoiding  a  solution  which 
can  satisfy  all. 

Experience  has  in  no  way  controverted  that  gained  in  civil 
practice  in  the  use  of  aseptic  methods,  but  has,  on  the  other  hand, 
proved  conclusively  that  advance  in  the  treatment  of  septic 
wounds  in  this  campaign  has  had  to  start  from  an  unfamiliar 
standpoint,  and  has  progressed  but  slowly.  Practical  application 
has  demonstrated  the  superiority  of  the  Listerian  principle  and 
method,  but  the  multiplicity  of  the  chemical  media  employed 
affords  evidence  enough  of  the  difficulty  met  with  in  establishing 
any  one  means  as  that  suitable  for  every  class  of  case.  On  two 
points  alone  can  no  difference  of  opinion  exist:  (1)  The  urgency 
of  an  efficient  primary  mechanical  cleansing  and  exposure  of  the 
wound  cavity,  and  (2)  the  importance  of  maintaining  the  wounded 
part  at  rest.  The  latter  point  raises  the  first  great  difficulty 
which  has  to  be  met  by  the  military  surgeon,  the  absolute  neces- 
sity of  early  transport  of  the  wounded  man;  and  lends  directly 
to  a  second,  the  amount  of  interference  advisable  in  wounds 
which  have  reached  the  "intermediate  stage,"  that  is,  the  period 
of  established  infection  during  its  first  phase,  the  condition,  in 
fact,  in  which  a  large  proportion  of  all  gunshot  wounds  reach 
the  general  hospitals  on  the  lines  of  communication. 

Speaking  generally,  it  has  been  shown  that  if  the  primary 
mechanical  cleansing  of  the  wound  has  been  thoroughly  carried 
out,  no  further  gross  intervention  should  be  necessary;  further, 
that  if  want  of  time  and  medical  officers  has  not  allowed 
of  this  procedure  being  fully  carried  out,  yet  if  the  wound  has 
been  sufficiently  opened  up  and  primary  drainage  ensured,  the 
subsequent  treatment  is  comparatively  simple.  From  the  point 
of  view  of  the  surgeon  on  the  lines  of  communication,  free  in- 
cisions are  never  objectionable,  provided  they  be  made  in  such 
directions  as  not  to  render  the  subsequent  secondary  closure 
of  the  wound  impracticable, — the  one  structure  for  which  he 
pleads  is  the  integument.  The  primary  cleansing,  given  satis- 
factory surroundings,  can  not  have  been  undertaken  too  early, 
as  every  hour  of  delay  adds  to  the  subsequent  task  of  dealing 
with  the  infection.  In  this  relation  the  immediate  removal  of 
shell  fragments  and  clothing  is  of  the  first  importance,  because 
if  allowed  to  remain,  the  deferred  operation,  even  in  minor 
wounds,  may  prove  a  procedure  of  great  danger  when  the  patient 


50  ABSTRACTS  OF  WAR  SURGERY 

has  arrived  at  the  general  hospital  on  the  lines  of  communica- 
tion. Such  an  apparently  trivial  operation  may  be  followed  at 
this  stage  by  an  acute  extension  of  anaerobic  infection  involving 
the  whole  segment  of  a  limb,  the  entire  member,  or,  indeed,  may  be 
sufficiently  extensive  to  lead  to  the  loss  of  the  limb,  or  even  the 
patient's  life. 

The  conditions  of  war,  however,  not  infrequently  prevent  an 
ideal  early  treatment  of  the  wounds.  It  may  be  impossible  to 
remove  patients  from  "No  Man's  Land,"  or  even  from  the 
trenches,  for  many  hours  or  even  days  after  reception  of  the 
wound.  On  the  occasion  of  serious  fighting  the  number  of  the 
wounded  may  make  it  impossible  for  the  requisite  amount  of  time 
to  be  spent  on  individuals,  especially  those  less  seriously  injured. 
Lastly,  unavoidable  delay  in  transport  may  result  in  extension  of 
infection  and  conversion  of  a  promising  case  as  it  left  the  casualty 
clearing  station  into  one  arriving  at  the  general  hospital  in  a 
highly  unsatisfactory  condition. 

Happily,  whatever  the  initial  procedure  and  application  may 
have  been,  in  many  cases  the  young  and  healthy  patients  arrive 
in  good  general  condition,  the  local  wound  progressing  satis- 
factorily, in  some  instances  devoid  of  any  serious  infection.  In 
a  considerable  proportion,  however,  men  are  admitted  suffering, 
both  generally  and  locally,  with  every  grade  of  infection  from 
the  slight  to  the  most  severe.  The  former  class  present  little 
difficulty,  the  wounds  heal  readily  under  any  form  of  simple  appli- 
cation, or,  as  a  time-saving  and  precautionary  measure,  the  smaller 
wounds  may  be  completely  excised  and  the  gap  sutured.  Wound 
excision,  of  wounds  in  general,  became  a  fixed  principle  later, 
and  is  now  most  enthusiastically  advocated  by  the  English 
surgeons  as  a  rule. 

A  vastly  more  difficult  problem  is  presented  by  patients  arriv- 
ing in  the  stage  of  acute  development  of  infections.  The  wound 
has  already  been  primarily  opened  up  and  cleansed,  and  the 
question  arises  whether  further  surgical  interference  will  effect 
improvement  or  lead  to  increased  extension  of  the  infective 
process.  On  the  one  hand,  it  is  evident  that  the  patient  is  suf- 
fering from  an  exacerbation  directly  due  to  the  disturbance 
involved  by  transport;  on  the  other,  the  possibility  is  always 
present  that  delay,  even  of  a  few  hours,  may  allow  such  progress 
as  to  render  any  further  intervention  useless.  A  rough-and- 
ready  distinction  between  cases  in  which  clinical  evidence  sug- 
gests anaerobic  or  aerobic  infection,  respectively,  to  predominate 
forms  the  most  useful  guide.    In  the  former  case  delay  may  be 


ABSTRACTS  OF  WAR  SURGERY  51 

fatal  to  life  and  limb,  in  the  latter  an  interval  of  rest  often 
results  in  a  rapid  subsidence  both  of  local  signs  and  general 
symptoms,   and  no  further  incision  may  be  required. 

Patients  arriving  at  the  general  hospitals  may  have  been  sub- 
jected to  several  varieties  of  primary  wound  treatment.  Speak- 
ing generally,  the  principles  adopted  have  consisted  in  the  main- 
tenance of  rest,  moisture,  and  an  antiseptic  application.  In  the 
earlier  stages  of  the  campaign  numerous  antiseptic  solutions 
were  employed,  also  the  hypertonic  saline  solution,  but  of  late, 
in  the  great  majority  of  cases,  solutions  of  which  the  active 
constituent  is  chlorine  have  found  most  favor  and  have  proved 
the  most  satisfactory  in  practice.  Eusol,  and  with  gradually 
increasing  frequency  the  Dakin-Daufresne  solution  of  hypo- 
chlorite of  sodium,  are  those  now  most  commonly  resorted  to. 
In  the  case  of  the  former,  moist  gauze  dressings,  in  combination 
with  ordinary  rubber  drainage  tubes,  have  been  generally  em- 
ployed; for  the  latter  the  technic  of  Carrel  is  used. 

A  smaller  number  of  cases  have  been  treated  by  other  methods, 
such  as  primary  suture,  the  salt  pack,  closure  after  the  introduc- 
tion of  a  mixture  of  iodoform,  bismuth  subnitrate  and  paraffin 
(Rutherford  Morison's  method),  a  solution  of  brilliant  green, 
etc.  A  word  may  be  added  regarding  the  salt  pack  method 
advocated  by  Colonel  H.  M.  W.  Gray.  This  method,  consisting 
in  a  thorough  packing  of  every  crevice  of  the  wound  with  gauze, 
between  the  layers  of  which  tablets  of  sodium  chloride  are  en- 
closed, is  suitable  for  wounds  of  the  large  funnel  type  or  of  a 
superficial  nature.  It  is  not  safe  for  tunnel  wounds,  wounds 
implicating  the  large  vessels,  or  highly  comminuted  fractures. 
The  early  action  of  the  sodium  chloride  is  inhibitory,  and  gives 
no  aid  to  the  healing  process;  indeed,  the  tablets,  even  when 
enveloped  in  gauze,  cause  local  necrosis  of  the  tissues  opposite 
to  them.  On  the  other  hand,  wounds  dressed  in  this  manner  may 
be  left  untouched  in  many  cases  for  a  week  or  ten  days,  during 
which  period  the  patient's  general  condition  remains  excellent. 
The  pack,  acting  as  a  foreign  body,  excites  a  local  reaction 
around  the  wound,  with  a  consequent  narrow  wall  of  inflamma- 
tory infiltration  which  protects  the  general  system  from  the 
absorption  of  toxic  products  from  the  wound.  Suitable  cases 
dressed  in  this  manner  arrive  in  a  surprisingly  good  condition 
at  the  general  hospitals,  and  the  wounds  do  well  with  subse- 
quent cleanly  antiseptic  treatment.  Subsequent  introductions 
of  the  pack  are  conducive  neither  to  rapid  closure  of  the  wound, 
to  cleanliness,  nor  to  the  amenities  of  the  ward,  and  are  undesirable. 


52  ABSTRACTS  OP  WAR  SURGERY 

It  may  be  well  here  to  mention  the  experience  which  has  been 
gained  as  to  three  points  in  the  technic  of  the  treatment  of 
septic  wounds — drainage,  irrigation,  and  baths. 

Drainage. — The  methods  of  maintaining  the  free  escape  of 
septic  discharges  from  the  wound  have  undergone  considerable 
modification,  although  no  doubt  has  arisen  as  to  the  cardinal  im- 
portance of  the  principle  to  be  carried  out.  In  the  earlier  stages 
of  the  war  it  was  effected  mainly  by  the  introduction  of  rubber 
tubes  of  large  caliber  and  other  devices  and  these  were  retained 
for  prolonged  periods  at  the  general  hospitals.  The  objections  to 
this  method — the  tendency  of  the  tube  to  form  for  itself  a  local- 
ized channel  useless  for  general  escape  of  fluid,  the  presence  of 
a  foreign  body  in  the  wound  capable  of  exercising  injurious  local 
pressure,  the  establishment  of  a  track  by  which  infection  could 
be  freely  conveyed  from  the  surface  to  the  depths  of  the  wound 
cavity,  and  lastly,  the  difficulty  of  determining  the  moment  at 
which  the  tube  might  be  safely  removed  after  its  prolonged  stay 
— were  obvious,  but  they  were  faced  for  a  time  in  view  of  the 
very  serious  infections  that  had  to  be  dealt  with.  A  revulsion, 
however,  soon  followed,  in  consequence  of  the  unsatisfactory 
results  attained,  and  the  tube  is  now  retained  as  a  provisional 
measure,  and  in  many  cases  not  employed  at  all.  The  main  ele- 
ment in  the  decreased  use  of  the  cylindrical  tube  has  been  the 
introduction  of  what  may  be  called  the  "curtain"  method.  This 
is  well  illustrated  in  two  forms  by  Carrel's  and  Rutherford  Mori- 
son's  systems  respectively.  In  Carrel's,  the  wound  surfaces  are 
kept  apart  not  by  the  small  tubes  employed  for  the  purpose  of 
instillation,  but  by  the  layer  of  fluid  constantly  renewed  between 
them  and  the  light  gauze  packing  introduced  to  retain  it.  In 
Rutherford  Morison's,  a  thin  layer  of  an  antiseptic  medium  cov- 
ers every  part  of  the  surface  of  the  exposed  tissues,  and  forms 
a  curtain  or  cleft  which  allows  for  the  escape  of  such  fluids 
as  may  collect  within  the  wound.  The  drainage  effected  by  the 
salt  pack  is  of  a  similar  character,  supplemented  by  the  absorp- 
tive power  of  the  pack  itself  before  it  becomes  thoroughly 
impregnated  with  the  discharges. 

Irrigation. — Continuous  irrigation  has  greatly  lost  in  favor;  it 
has  the  primary  objection  of  inconvenience  to  the  patient,  while 
experience  has  demonstrated  the  difficulty  of  preventing  the 
fluid  from  forming  definite  runlets,  and  consequently  of  ensur- 
ing the  flow  of  the  fluid  employed  over  the  whole  surface  of  the 
wound.    Its  use  has  consequently  been  more  and  more  restricted ; 


ABSTRACTS  OF  WAR  SURGERY  53 

and,  except  in  the  form  of  a  periodical  flush,  irrigation  is  little 
employed. 

Baths. — Antiseptic  baths  have  also  lost  in  favor  with  the 
development  of  more  effective  antiseptic  methods.  Beyond  the 
obvious  difficulties,  the  bath  entails  the  serious  disadvantage,  in 
dealing  with  a  septic  limb,  of  the  impracticability  of  preventing 
hurtful  movements  of  the  part. 

At  the  present  time  the  most  successful  results  that  are  being 
attained  in  all  forms  of  wound  are  undoubtedly  those  in  which 
the  Carrel-Dakin  method  is  employed.  This  method  has  not  only 
shown  itself  successful  in  the  early  treatment,  but  also  in  the 
later  treatment  of  septic  wounds,  even  in  the  stage  of  chronic 
established  suppuration.  It  has  been  definitely  proved  that  simple 
flesh  wounds  dealt  with  during  the  first  twelve  hours  after 
infliction  can  be  rendered  practically  sterile  in  an  average  of 
six  days,  those  dealt  with  later  in  an  average  of  twelve  days, 
that  compound  fractures  may  be  sterilized  within  three  weeks, 
and  that  all  three  classes  of  cases  may  be  secondarily  sutured  and 
closed  at  these  dates.  Economy  in  time,  diminution  in  the  risks 
of  secondary  complications,  increase  in  the  comfort  and  well- 
being  of  the  patient  during  treatment,  are  all  insured  by  the 
method. 

It  also  insures  what  has  become  the  supreme  object  in  dealing 
with  septic  wounds,  the  possibility  of  early  secondary  suture. 
The  importance  of  using  a  bacteriological  test  to  determine  the 
date  of  closure  of  the  wound  can  not  be  too  strongly  impressed 
if  anything  like  habitual  success  is  to  be  attained.  Opportunity 
has  not  yet  been  afforded  for  the  trial  of  the  method  during  a 
great  rush  of  wounded  men,  but  arrangements  have  been  made 
to  carry  it  out  if  possible.  Even  should  this  prove  impracticable, 
the  system  can  readily  be  carried  out  in  quieter  times  for  a  very 
large  number  of  patients.  It  has  one  obvious  advantage  over  any 
other  method  of  treating  septic  wounds,  the  production  of  a  thin 
supple  scar,  not  likely  to  interfere  with  the  mobility  of  the 
parts,  or  to  cause  trouble  by  subsequent  contraction. 

The  alternative  method  of  secondary  closure,  that  of  Ruther- 
ford Morison,  avoids  the  tedious  process  and  careful  manipula- 
tion essential  to  the  success  of  Carrel's  method,  saves  much 
time  on  the  part  of  both  surgeons  and  nurses,  and  the  patient 
has  not  to  undergo  the  discomfort  of  repeated  dressings.  Little 
experience  has  yet  been  gained  of  its  suitability  as  a  primary 
procedure,  but  in  infected  suppurating  wounds  it  has  attained 
great  success.     It  must,  however,  be  allowed  that  the  cicatrix 


54  ABSTRACTS  OF  WAR  SURGERY 

obtained  is  very  inferior  to  that  which  follows  the  use  of  Carrel's 
system,  "from  the  initial  period  onward,  and  the  inclusion  of  par- 
ticles of  bismuth  and  iodoform  has  some  disadvantages,  both 
immediate  and  remote.  One  great  advantage  of  Rutherford 
Morison's  method  is  also  lost  in  the  cases  treated  by  it  in  a  field 
ambulance  or  casualty  clearing  station  and  the  patients  must 
undergo  transport  with  its  consequent  shaking  and  disturbance 
of  the  wound;  hence,  patients  with  the  slighter  injuries,  whose 
wounds  have  been  closed  by  this  method,  often  arrive  with  the 
composition  escaping  from  a  wound  in  which  little  or  no  union 
has  taken  place,  and  no  appreciable  benefit  has  been  conferred. 

While  it  may  be  said  fairly  that  the  Listerian  principle  has 
been  more  nearly  attained  by  the  method  of  Carrel  than  by  any 
other  in  use,  and  that  the  results  are  of  a  very  satisfactory 
nature,  yet  it  must  still  be  allowed  that  an  ideal  antiseptic 
medium  remains  to  be  found,  especially  in  respect  of  consistency 
of  strength  and  persistence  in  action.  In  both  respects  the  bis- 
muth iodoform  methods  offer  some  advantages  to  make  up  for 
the  cruder  character  of  the  cosmetic  results  obtained. 

Secondary  Hemorrhage. — As  a  manifestation  of  septic  infec- 
tion, it  is  obvious  that  improved  methods  of  wound  treatment 
offer  the  best  chance  of  reducing  the  frequency  of  secondary 
hemorrhage,  and  it  may  be  confidently  stated  that  with  the  devel- 
opment of  more  satisfactory  methods  the  accident  has  become 
less  common.  Still  it  must  be  recognized  that  in  dealing  with 
gunshot  wounds  we  are  likely  to  be  of  necessity  limited  to  the 
process  of  secondary  sterilization  of  an  infected  wound ;  further, 
that  we  stand  in  the  face  of  a  variety  of  wounds  in  which  incom- 
plete primary  lesions  of  the  blood  vessels  are  more  common  than 
in  any  other.  The  eventual  perforation  of  the  vessel  wall,  there- 
fore, is  up  to  a  certain  date  more  commonly  the  result  of  the 
separation  of  a  slough  of  primarily  devitalized  tissue  than  due 
to  the  extension  of  a  process  of  ulceration  from  without. 

Secondary  hemorrhage  may  occur  from  any  large  vessel,  or  in 
old  toxemic  or  septicemic  subjects  it  may  be  of  the  parenchyma- 
tous variety.  Given  this  generalization,  however,  we  find  that 
certain  vessels  are  much  more  commonly  the  source  of  bleeding 
than  others.  The  localization  is  determined  by  the  degree  of 
fixation  of  the  vessel  and  the  firmness  of  the  bed  upon  which  it 
lies.  Thus  the  circumflex  branches  of  the  axillary  artery,  the 
subscapular  or  posterior  scapular  vessels  in  proximity  to  the 
scapular,  the  gluteal  artery,  the  articular  branches  of  the 
popliteal  artery,  the  circumflex  branches  of  the  profunda  femoris, 


ABSTRACTS  OP  WAR  SURGERY  55 

the  femoral  artery  in  the  lower  part  of  Hunter's  canal,  and  the 
anterior  tibial  artery  as  it  lies  on  the  interosseous  membrane,  are 
all  common  sites,  and,  it  may  be  also  remarked,  troublesome  ones 
in  which  to  deal  comfortably  with  the  injured  vessel.  Another 
peculiarity  is  the  comparative  frequency  with  which  large  trunks 
in  mobile  positions,  such  as  Scarpa's  triangle,  may  escape  damage 
by  displacement  and  lie  exposed  on  the  surface  of  a  large  open 
wound.  Such  vessels  may  not  infrequently  have  suffered  con- 
tusion with  consequent  thrombosis. 

As  to  the  general  treatment  of  these  injured  vessels,  little  new 
has  been  evolved;  direct  local  ligature,  prolonged  forcipressure, 
or  at  the  last  extremity  local  plugging,  are  still  the  means  on 
which  the  surgeon  must  depend.  On  rare  occasions,  as  an 
emergency  measure,  a  proximal  ligature  may  be  applied,  but  this 
is  rarely  successful  and  often  harmful.  A  single  exception  to 
this  rule  must  be  allowed  in  case  of  uncontrollable  hemorrhage 
from  wounds  of  the  gluteal  region;  here  in  several  instances 
ligature  of  either  the  internal  iliac  artery  or  its  posterior  trunk 
has  proved  a  successful  measure. 

The  proper  method  of  treatment  of  an  exposed  arterial  trunk, 
whether  thrombosed  or  not,  has  opened  up  a  question  upon 
which  the  civil  surgeon  rarely  has  to  form  a  decision.  It  may  be 
broadly  stated  that  the  line  of  treatment  depends  mainly  upon 
the  degree  of  septicity  of  the  wound  of  the  surrounding  soft 
parts.  If  the  arterial  coats  are  not  seriously  damaged  and  the 
wound  be  in  a  condition  likely  to  respond  to  antiseptic  treat- 
ment, an  expectant  attitude  should  be  assumed  if  the  vessel  be 
pervious.  If,  on  the  other  hand,  the  artery  is  thrombosed,  the 
right  course  is  to  place  ligatures  both  above  and  below  the  oblit- 
erated portion  of  the  vessel,  because  such  arterial  thrombi  in  any 
case  result  in  permanent  occlusion,  while  in  many  instances  the 
vessel  may  give  way  at  the  limits  of  the  clot,  a  solid  cylinder, 
like  a  pencil,  coming  away  with  great  risk  of  hemorrhage ;  beyond 
this  the  clot  provides  a  possible  source  of  a  peripheral  embolus. 

As  to  the  general  treatment  of  patients  in  whom  a  secondary 
hemorrhage  has  occurred,  internal  styptics  such  as  calcium 
lactate  have  proved  useless.  This  is  easily  intelligible  in  the  case 
of  the  larger  vessels,  for  in  such  a  more  or  less  rounded  opening 
is  usually  present,  the  occlusion  of  which  by  a  mural  clot  is  of 
no  more  than  very  temporary  use,  while  a  local  thrombus  ob- 
structing the  whole  lumen  is  unlikely  to  form.  Even  in  cases 
of  the  parenchymatous  variety  internal  remedies  have  proved 
useless. 


56  ABSTRACTS  OF  WAR  SURGERY 

The  main  advance  in  treatment  has  consisted  in  a  return  to  the 
practice  of  transfusion  of  "whole  blood"  which  has  in  great 
measure  displaced  the  unsatisfactory  saline  infusion.  For  the 
popularization  of  this  method  we  are  mainly  indebted  to  our 
Canadian  colleagues  in  France.  Several  methods  have  been 
employed — the  Kimpton  tube,  the  Unger  two-way  stopcock,  direct 
connection  of  the  radial  artery  of  the  donor  with  the  vein  of  the 
recipient  by  a  paraffin-coated  rubber  tube  provided  with  silver 
cannulas  at  either  end,  the  employment  of  a  series  of  Record 
syringes,  or  the  citrated  method. 

Generally  speaking,  the  good  results  have  been  obtained  in 
cases  of  pure  anemia ;  when  the  anemia  has  depended  in  part  on 
hemorrhage,  in  part  on  septic  infection,  the  procedure  has  not 
been  satisfactory.  Again,  it  has  been  more  frequently  successful 
as  a  measure  in  primary  than  in  secondary  hemorrhages. 

Military  conditions  have  allowed  small  opportunity  for  pre- 
liminary hemolytic  tests  applied  to  either  donor  or  recipient,  but, 
when  practicable,  a  small  preliminary  transfusion  of  10  c.c.  of 
the  donor's  blood  has  been  made  the  day  previous  to  the  main 
procedure;  accidents  due  to  hemolytic  reaction  have  not,  how- 
ever been  common.  In  a  few  cases  alarming  symptoms  have 
passed  off  with  no  further  result  when  the  transfusion  was  dis- 
continued, and  two  patients  have  probably  died  as  a  direct  result 
of  the  treatment.  Ill  effects  have  not  been  sufficiently  numerous, 
however,  to  raise  the  question  of  justifiability  in  the  desperate 
cases  for  which  the  procedure  is  undertaken. 

Tetanus. — Tetanus,  the  terrible  scourge  which  gave  rise  to  so 
great  anxiety  in  the  autumn  and  early  winter  of  1914,  has  become 
a  comparatively  infrequent  wound  complication  since  the  adop- 
tion of  prophylactic  injections  of  antitoxin  in  all  cases  of  wounds 
and  in  cases  of  "trench  foot"  accompanied  by  vesication.  Never- 
theless cases  still  occur,  in  some  instances  because  the  primary 
injection  has  been  given  late  as  a  result  of  the  patients'  not  being 
able  to  be  "collected"  from  the  zone  of  fire,  a  few  men  escape 
treatment  as  a  consequence  of  the  number  of  wounded  needing 
to  be  dealt  with  after  a  serious  engagement,  and  special  idiosyn- 
crasy may  account  for  others.  At  an  early  date  it  was  also  recog- 
nized that  the  protective  influence  of  the  antitoxin  is  often 
exhausted  at  the  end  of  eight  or  ten  days ;  hence  a  general  order 
was  given  to  the  effect  that  the  injections  should  be  repeated  at 
intervals  of  seven  days  in  all  cases  of  serious  wound  and  to 
patients  whose  wounds  were  not  progressing  well. 

The  cases  met  with  include  every  degree  and  variety  of  the 


ABSTRACTS  OF  WAR  SURGERY  57 

disease.  Thus,  very  acute  cases  with  general  spasms,  slight  cases 
in  which  trismus  is  the  main  feature,  cases  of  "head  tetanus" 
either  of  the  paralytic  class  or  with  clonic  spasms  of  the  muscles 
of  mastication,  splanchnic  tetanus,  local  tetanus  of  the  limbs, 
sometimes  remaining  confined  to  the  wounded  member,  in  others 
becoming  general,  and  cases  of  the  so-called  delayed  class.  In 
one  remarkable  instance  of  the  last  variety  the  patient,  who  had 
been  sent  to  England  in  August  with  a  small  wound  of  the  but- 
tock, at  the  bottom  of  which  was  a  small  retained  foreign  body, 
returned  to  duty  two  months  later.  When  on  duty  in  the  trenches 
stiffness  of  the  corresponding  limb,  at  first  ascribed  to  sciatica, 
developed,  and  later  general  tetanic  symptoms.  Active  treatment 
with  antitoxin  was  followed  by  an  uninterrupted  recovery. 

Accumulated  experience  has  negatived  the  utility  of  treatment 
with  carbolic  acid  or  magnesium  sulphate,  both  of  which  remedies 
were  vaunted  in  the  early  stages  of  the  campaign.  Curative 
treatment  by  antitoxin  is  still  upon  its  trial,  and  considerable 
difference  of  opinion  exists  both  as  to  its  utility  and  as  to  which 
route  should  be  chosen  for  its  exhibition.  The  subcutaneous 
route  is  generally  considered  unsatisfactory  on  account  of  the 
delay  in  conveyance  of  the  antitoxin  to  the  required  area ;  hence, 
although  generally  chosen  for  prophylactic  purposes,  its  use  as 
a  method  of  curative  treatment  is  restricted  to  an  auxiliary  role. 
The  intramuscular  route  has  found  more  favor,  although  its 
efficacy  is  doubted  by  many.  The  intravenous  route  has  not  been 
shown  to  be  specially  efficacious,  and  as  accidents  of  an  anaphy- 
lactic character  have  followed  its  use  it  has  been  practically 
abandoned.  The  general  applicability  of  the  intrathecal  route  is 
still  under  discussion;  the  chief  objection  to  its  use  lies  in  the 
large  quantity  of  serum  which  requires  to  be  introduced  and  the 
comparatively  serious  nature  of  the  procedure  itself  if  repeated 
injections  are  made.  In  some  cases  a  definite  disturbance  of  the 
intracranial  pressure  appears  to  result,  and  in  some  local  inflam- 
matory changes  in  the  spinal  theca  have  occurred.  In  spite  of 
these  objections  the  intrathecal  method  has  been  very  largely 
employed,  and  a  trial  is  now  being  made  of  a  highly  concentrated 
antitoxin. 

The  prognosis  has  depended  in  individual  cases  on  the  length 
of  the  incubation  period,  and,  in  spite  of  treatment,  the  mortality 
has  remained  above  70  per  cent  of  all  cases  treated.  Symptomatic 
treatment  by  chloral  and  morphine,  particularly  the  former,  has 
retained  its  character  both  in  the  relief  of  suffering  and  as  cura- 


58  ABSTRACTS  OF  WAR  SURGERY 

tive,  in  so  far  as  it  tends  to  delay  exhaustion  dependent  on  the 
spasms. 

Other  Wound  Infections. — Little  new  can  be  said  regarding  the 
remaining  forms  of  wound  infection,  but  it  may  be  generally 
stated  that  the  antiseptic  solutions  depending  upon  chlorine  for 
their  active  element  have  proved  the  most  successful  application. 
One  form  of  streptococcus  infection  deserves  special  mention  as 
possibly  corresponding  to  the  variety  of  "classical  hospital  gan- 
grene" described  as  the  membranous.  Cases  of  this  nature  have 
not  been  common,  although  sufficiently  so  to  have  become 
familiar.  A  wound  which  has  previously  been  apparently  pro- 
gressing favorably  becomes  covered  with  a  dense  grey  tough 
membrane,  firmly  adherent  to  the  subjacent  granulations.  In  the 
earliest  stage  this  membrane  does  not  materially  differ  from  the 
thin  layer  of  coagulated  fibrin  and  included  leucocytes  which 
not  uncommonly  forms  in  cases  of  streptococcic  infection  which 
after  a  time  fail  to  respond  to  treatment.  The  same  cessation 
of  free  discharge  from  the  wound  surface  is  observed,  a  condi- 
tion well  described  by  Colonel  Almroth  Wright,  as  ''lymph 
bound."  The  membrane  then  thickens  so  as  to  resemble  one  of 
the  diphtheritic  class;  in  fact  strong  suspicion  was  aroused  in 
the  earlier  stages  of  the  war  that  the  change  was  due  to  a 
diphtheritic  infection.  Bacteriological  examination  has,  how- 
ever, in  all  cases  resulted  in  the  discovery  of  streptococci  alone. 
With  the  development  of  the  membrane  a  continuously  increas- 
ing hard  white  edema  spreads  up  the  limb  or  on  to  the  trunk,  the 
patient  meanwhile  suffering  with  pronounced  signs  of  toxemia. 
Incisions  into  the  edematous  area  give  rise  only  to  the  escape  of 
a  small  amount  of  serous  discharge,  and  the  tension  wounds  tend 
to  dry  up  with  little  change.  Amputation  is  usually  followed  by 
a  recurrence  of  the  same  type  of  wound  surface,  and  the  patient 
dies  in  from  four  days  to  a  week's  time  after  the  commence- 
ment of  the  process.  No  successful  method  of  dealing  with  this 
special  form  of  wound  infection  has  been  devised. 

Septicemia. — The  most  common  form  has  been  in  connection 
with  streptococcal  infections.  It  can  not  be  said  that  any  ad- 
vance has  been  made  in  the  treatment  of  this  condition.  A  more 
or  less  extended  trial  has  been  made  of  intravenous  injections 
of  hypochlorous  acid  in  the  form  of  eusol,  but  no  satisfactory 
results  have  been  obtained.  The  same  remark  obtains  to  a  more 
limited  trial  with  colloid  chloride  of  gold.  The  work  of  Dakin 
has  shown  that  the  antiseptic  power  of  injections  of  eusol  must 
be  small  in  consequence  of  the  minute  amount  of  the  antiseptic 


ABSTRACTS  OF  WAR  SURGERY  59 

in  proportion  to  the  volume  of  the  patient's  blood.  If  either 
this  solution  or  that  of  chloride  of  gold  can  effect  any  useful 
purpose,  it  is  probably  only  by  exciting  as  irritants  a  certain 
degree  of  activity  in  the  endothelial  lining  of  the  blood  vessels, 
and  in  neither  case  has  this  proved  sufficient  to  serve  the  pur- 
pose aimed  at  of  sterilizing  the  blood. 

Injuries  to  the  Great  Vessels. — The  dangerous  nature  of  in- 
juries to  the  great  vascular  trunks  has  been  amply  demonstrated 
by  the  fact  that,  except  one  or  two  injuries  to  the  innominate 
vessels,  the  subclavian  artery  in  the  thoracic  part  of  its  course, 
and  possibly  a  few  to  the  iliac,  injuries  to  the  vessels  of  the  trunk 
have  been  conspicuous  by  their  absence  on  the  lines  of  com- 
munication. 

A  considerable  experience  has  been  gained  regarding  the  ef- 
fects of  contusion  of  the  vessels,  which  has  in  the  main  sub- 
stantiated the  French  pre-war  experimental  observations.  At 
the  same  time,  the  occurrence  of  single  simple  linear  fissures  of 
the  intima  has  been  a  more  common  form  of  lesion  than  one 
would  have  been  led  to  expect.  The  chief  importance  of  these 
lesions  has  been  in  connection  with  secondary  hemorrhage,  and 
in  the  frequency  with  which  the  injury  is  followed  by  throm- 
bosis. Several  instances  of  subsequent  embolism  has  been  ob- 
served, this  particularly  in  the  case  of  the  cervical  vessels,  where 
cerebral  embolisms  are  readily  detected  as  a  consequence  of  the 
obvious  signs  with  which  blockage  of  the  cerebral  vessels  is 
attended.  This  experience,  combined  with  that  of  similar  acci- 
dents occurring  in  connection  with  actual  wounds  of  the  vessels, 
raises  the  question  of  how  great  a  proportion  of  the  instances 
of  gangrene  of  the  extremities  following  injuries  to  the  vessels 
of  the  limbs,  either  spontaneous  or  following  ligature,  is  due 
solely  to  the  local  occlusion  of  the  main  vessels.  It  seems  likely, 
if  all  these  cases  could  be  thoroughly  investigated,  that  em- 
bolism in  the  distal  circulation  plays  a  more  important  part  than 
has  hitherto  been  accorded  to  it. 

The  frequency  with  which  various  forms  of  missile  have  been 
employed  has  been  followed  by  considerable  change  in  the  na- 
ture of  the  lesions,  the  highly  contused  lateral  wound  of  the 
artery,  and  the  clean  perforation  made  by  the  modern  bullet, 
have  of  late  been  less  in  evidence  than  extensive  lateral  lacera- 
tions and  more  or  less  limited  lateral  perforations  caused  by 
fragments  of  shells  or  minute  fragments  derived  from  bombs. 
Occlusion  of  wounds  of  the  vessels  by  retained  shell  fragments, 
the  removal  of  which  has  been  followed  by  free  hemorrhage, 


60  ABSTRACTS  OF  WAR  SURGERY 

has  not  been  rare.  On  the  other  hand,  instances  of  missiles  en- 
tering and  traveling  along  the  blood  vessels  have  rarely  been 
observed.  The  most  striking  instances  have  been  those  in  which 
shrapnel  balls  have  obtained  entrance  to  the  heart  or  large 
veins  of  the  trunk  and  travelled  downwards  by  gravitation.  The 
most  interesting  feature  of  these  cases,  observed  also  in  some 
wounds  of  the  inferior  vena  cava,  is  the  moderate  degree  of 
primary  hemorrhage  which  had  taken  place. 

Wounds  of  the  great  vessels  arrive  in  the  hospitals  on  the 
lines  of  communication  usually  some  days  after  their  infliction, 
but  a  considerable  proportion  may  arrive  at  an  earlier  date  in 
consequence  of  the  absence  of  primary  hemorrhage,  or  the  co- 
existence of  some  more  serious  or  more  easily  recognized  injury 
having  allowed  them  to  be  overlooked.  This  is  especially  the 
case  in  multiple  bomb  or  shell  injuries,  where  one  out  of  twenty 
small  wounds  produced  by  as  many  fragments  widely  distributed 
over  the  whole  body  may  have  implicated  an  artery;  or  in  the 
case  of  severe  fractures  of  the  long  bones,  accompanied  by  great 
swelling  of  the  soft  parts. 

The  result  of  this  experience  has  been  greatly  to  widen  the 
scope  of  the  stethoscope  in  the  diagnosis  of  arterial  injuries,  since 
auscultation  will  often  reveal  the  presence  of  the  pathognomonic 
systolic  bruit,  when  the  absence  of  local  pulsation  in  the  swollen 
area  and  the  presence  of  pulsation  in  the  distal  arterial  circula- 
tion may,  if  depended  upon  alone,  lead  to  a  serious  error  in 
diagnosis.  Further,  it  has  been  observed  that  the  local  vascular 
bruits  may,  in  some  third  of  the  whole  number  of  injuries  to  ar- 
teries of  the  lower  extremity,  and  less  frequently  in  other  ves- 
sels, be  conveyed  to  the  cardiac  area,  and  distant  vascular  lesions 
have  in  some  cases  been  detected  by  the  presence  of  the  appar- 
ently cardiac  murmur.  This  phenomenon  is  observed  both  in 
pure  arterial  and  arteriovenous  injuries.  It  has  also  been  ob- 
served that  the  distal  blood  pressure  of  the  limb  is  materially 
lowered  in  the  presence  of  a  lateral  arterial  lesion — in  fact,  prac- 
tically to  the  same  degree  as  if  the  main  vessel  has  been  occluded. 

As  a  consequence  of  the  period  at  which  arterial  injuries  reach 
the  hospitals  on  the  lines  of  communication  the  treatment  has 
been  for  the  most  part  expectant,  the  large  majority  of  the  pa- 
tients being  evacuated  to  the  base  in  England.  The  importance 
of  rest  in  allowing  subsidence  of  the  general  circulatory  excite- 
ment, and  the  consolidation  of  the  aneurysmal  tumor,  has  been 
obvious.  It  is  also  held  that  during  this  period,  the  enlargement 
of  the  collateral  circulation  makes  some  progress.  Some  evidence 


ABSTRACTS  OF  WAR  SURGERY  61 

in  favor  of  this  view  is  offered  by  the  fact  that  the  nutrition  of 
the  limb  is  not  observed  to  suffer  during  this  period,  while  wast- 
ing, sometimes  of  a  rapid  character,  often  follows  the  perform- 
ance of  necessary  ligation. 

Accidents  during  this  probationary  period  have  not  been  com- 
mon ;  gangrene  has  been  rare ;  secondary  hemorrhage  uncommon, 
unless  the  wounds  were  large  and  badly  infected ;  and  suppura- 
tion of  the  aneurysm  has  been  an  accident  of  extreme  infrequency. 

Active  treatment  has  consisted,  in  the  main,  of  ligature  of  the 
vessels.  This  has  been  indicated  by  extension  of  the  blood  effusion 
in  the  limb,  secondary  hemorrhage,  signs  of  pressure  on  the  trunk 
by  increasing  size  and  firmness  of  the  false  aneurysmal  sac,  or 
signs  of  inflammation.  When  the  hospital  accommodation  has 
allowed  a  sufficiently  long  stay  a  certain  number  of  cases  have 
been  operated  upon  in  the  absence  of  any  untoward  symptoms. 

For  purely  arterial  injuries,  ligature  of  the  vessel  above  and 
below  the  wounded  spot  has  been  the  most  common  operation. 
In  a  number  of  these  cases  the  main  vein  has  been  found  to  be 
thrombosed,  but  this  accident  has  not  had  any  adverse  influence 
on  the  result.  The  same  statement  may  be  made  as  to  the  results 
observed  when  coexisting  wound  of  the  vein  has  made  it  obliga- 
tory to  tie  both  vein  and  artery,  or  in  the  cases  where  the  main 
vein  had  already  suffered  complete  division  and  occlusion.  The 
same  experience  has  followed  ligature  of  both  artery  and  vein 
above  and  below  the  communicating  channel  in  arteriovenous 
aneurysms  or  aneurysmal  varices.  Hence  it  has  been  claimed 
that  simultaneous  occlusion  of  both  artery  and  vein  is  a  neg- 
ligible occurrence  with  regard  to  any  increase  of  risk  to  the 
vitality  of  the  limb.  Further,  that  insomuch  as  a  better  balance 
is  maintained  between  the  arterial  and  venous  elements  of  the 
collateral  circulation,  and  the  blood  pressure  within  the  limb 
increased,  the  operation  is  preferable  to  that  confined  to  the 
wounded  artery  alone. 

In  certain  vessels — for  example,  common  carotid,  common 
femoral,  popliteal — after  ligature  of  which  acute  local  anemia  and 
gangrene  is  specially  liable  to  follow,  a  limited  trial  has  been 
made  of  Tufner's  tubes  to  maintain  temporarily  the  main  cur- 
rent pending  the  increase  of  the  collateral  circulation.  In  a 
small  series  of  eight  cases  (common  carotid  1,  axillary  1,  femoral 
2,  popliteal  4)  in  which  this  method  was  used,  in  no  instance  did 
gangrene  take  place.  In  one  femoral  case,  in  which  the  tibial 
pulses  were  absent  at  the  time  of  operation,  feeble  pulsation  re- 
turned and  persisted  for  a  few  hours,  and  in  the  second  the  foot, 


62  ABSTRACTS  OF  WAR  SURGERY 

which  had  been  cold,  at  once  became  warmer  and  remained  so. 
Such  evidence  as  has  been  obtained,  however,  does  not  suggest 
that  the  maintenance  of  the  main  current  persisted  more  than  a 
few  hours,  and  the  clots  expressed  from  the  tubes  when  removed 
on  the  fourth  day,  although  firm  in  comparison  with  the  terminal 
projecting  into  the  proximal  end  of  the  vessel,  did  not  suggest 
a  very  gradual  formation.  Moreover,  in  one  of  the  popliteal 
cases,  in  which  it  would  have  been  difficult  to  place  a  ligature  on 
the  lower  end  of  the  artery,  it  was  not  found  necessary  to  do  so, 
as  the  vessel  was  closed  by  a  firm  thrombus.  Such  experience  as 
has  been  gained  is,  however,  definitely  in  favor  of  a  more  ex- 
tended trial  of  this  method. 

Suture  of  the  vessels,  either  end-to-end  or  lateral,  has  been 
employed  only  in  few  cases.  At  the  period  during  which  the 
patients  are  still  in  the  hospitals  on  the  lines  of  communication 
the  vessels  are  still  comparatively  fixed  and  difficult  to  free  with- 
out damage  to  the  coats,  as  well  as  rigid  in  themselves;  hence, 
if  sutures  are  introduced,  the  tension  upon  them  is  far  greater 
than  is  the  case  with  normal  arteries.  Again,  a  large  proportion 
of  the  wounds  are  too  extensive  for  anything  but  an  end-to-end 
union  after  removal  of  the  damaged  extremities  of  the  vessel, 
and  here  again  both  local  tension  and  an  undesirable  temporary 
flexion  of  the  limb  to  reduce  it  are  opposed  to  successful  suture. 
Cases,  however,  do  occur  in  which  either  form  of  operation  can 
be  carried  out.  In  a  small  series  of  six  operations  the  following 
immediate  results  were  obtained:  Brachial  3:  (a)  Lateral  suture, 
lumen  of  vessel  reduced  more  than  one-third;  no  radial  pulse 
before  operation,  but  it  returned  four  days  after,  (b)  Refresh- 
ment of  ends  and  end-to-end  suture.  Radial  pulse  palpable  after 
operation  and  persisted.  At  the  end  of  the  third  week  the  distal 
blood  pressure  in  the  limb  had  risen  by  22  mm.  of  mercury,  (c) 
Excision  and  end-to-end  suture.  Radial  pulse  absent  during  first 
two  days  after  operation,  then  returned.  Five  days  after  the 
operation  the  distal  blood  pressure  was  30  mm.  of  mercury  greater 
than  before.  Popliteal  1:  Lateral  suture.  A  good  anterior  tibial 
pulse  was  present  the  day  after  operation,  but  the  posterior  tibial 
was  absent.  Femoral  2:  (a)  Lateral  suture  of  an  arteriovenous 
communication  of  six  months '  standing.  Distal  tibial  pulses  pres- 
ent at  the  end  of  the  operation  and  persisted,  (b)  Lateral  suture 
in  Hunter's  canal.  Tibial  pulses  absent  before  operation,  but 
were  just  palpable  four  days  later.  Distal  blood  pressure  still 
50  mm.  of  mercury  lower  than  in  other  limb. 

Time  and  a  considerably  more  extended  observation  is  needed 


Abstracts  of  war  surgery  63 

to  determine  whether  the  operation  of  suture  does  attain  very 
much  better  results  than  simple  ligature.  The  above  results,  in- 
cluding no  sort  of  accident,  seem  to  do  little  more  than  prove 
that  the  operation  is  practicable  and  not  dangerous  in  selected 
cases.  That  a  patent  lumen  is  preserved  in  the  vessels  in  the 
majority  of  cases  is,  however,  not  yet  proved. 

Fractures. — At  an  early  stage  in  the  campaign,  when  wounded 
men  were  streaming  in  large  numbers  into  the  improvised  hos- 
pitals in  Boulogne,  it  became  evident  that  neither  the  regulation 
outfit  of  splints  nor  the  supply  of  emergency  splints  manufac- 
tured by  the  mechanics  attached  to  each  hospital  unit  sufficed  to 
cope  with  the  large  number  of  fractures  admitted.  An  oppor- 
tune paper  by  Lieutenant-Colonel  Robert  Jones  which  appeared 
about  this  moment  moreover  impressed  all  those  concerned  in 
the  treatment  of  these  injuries  with  the  enormous  advantages 
offered  by  splints  of  the  H.  0.  Thomas  class  for  military  use, 
both  in  facilitating  the  early  and  safe  transport  of  patients,  and 
in  allowing  efficient  extension  of  the  limbs  to  be  continuously 
maintained.  Further  a  number  of  modifications  of  the  type  of 
splints  which  have  subsequently  proved  of  much  value  were 
quickly  in  demand.  In  order  to  meet  the  requirements  thus  sud- 
denly arising,  application  was  made  to  the  Medical  Director- 
General  at  the  War  Office  for  the  supply  of  a  skilled  surgical 
mechanician  to  undertake  the  control  of  a  central  splint  manufac- 
tory at  Boulogne.  Mr.  Salmon  was  sent  out,  and  since  that  time 
an  enormous  number  of  splints  have  been  manufactured  locally 
and  supplied  not  only  to  the  general  hospitals  on  the  lines  of 
communication,  but  also  to  advanced  units  throughout  the  army. 
It  would  be  difficult  to  overestimate  the  practical  value  of  this 
establishment. 

The  first  question  which  has  arisen  in  connection  with  these 
injuries  is  the  relative  importance  of  the  primary  treatment  of 
the  wound  of  the  soft  parts,  or  the  adjustment  of  the  bony  frag- 
ments themselves.  Cases  may  occur  in  which  either  assumes 
the  first  place — thus  the  limb  may  be  threatened  by  anaerobic 
infection ;  reduction  of  the  displacement  and  maintenance  of  the 
bone  in  position  may  prove  a  matter  of  extreme  difficulty  as  a 
result  of  the  position  and  direction  of  the  fracture;  or  the  pres- 
ence of  multiple  wounds  in  inconvenient  positions  may  render 
it  impossible  to  apply  such  apparatus  as  will  maintain  sufficient 
extension.  Under  any  of  these  circumstances  treatment  of  the 
wounded  soft  parts  may  claim  priority,  but  as  a  general  rule  the 
principle   of  prompt  reduction  of  the   displacement  and  main- 


64  ABSTRACTS  OF  WAR  SURGERY 

tenance  of  extension  has  been  adhered  to.  It  has  been  recognized 
that  secondary  efforts  at  reduction  when  a  septic  wound  has 
cleaned  and  settled  down  is  a  serious  operation  involving  risks 
of  lighting  up  again  a  condition  which  has  been  with  difficulty 
overcome. 

The  next  question  which  arises  is  whether  rigid  extension  in 
the  direct  long  axis  of  the  limb  is  to  be  maintained  or  the  joints 
placed  in  the  flexed  position.  For  patients  treated  in  France  the 
former  method  has  been  the  more  widely  adopted,  in  order  to 
utilize  the  facilities  in  transport  which  the  Thomas  splints  un- 
doubtedly offer.  As  an  invariable  custom,  however,  this  practice 
has  not  been  able  to  be  followed,  as  many  surgeons  have  not 
been  able  to  obtain  good  position  of  the  fragments  in  such  posi- 
tions as  the  upper  and  lower  thirds  of  the  femur.  To  meet  this 
difficulty  the  Thomas  splints  have  been  bent  or  other  methods 
employed.  For  instance,  Hodgen's  splint  for  the  upper  third  of 
the  thigh  bone,  or  a  swinging  frame  of  the  same  dimensions  of 
the  bed,  the  feet  being  fixed  by  plaster  extension  strips  to  the 
angles  of  the  lower  end,  and  the  head  and  body  lowered.  For 
the  lower  third  the  wire  double-inclined  plane  of  Hey  Groves  has 
occasionally  been  employed.  All  these  methods,  however,  require 
additional  attention  and  longer  stay  in  France,  hence  they  have 
not  been  widely  resorted  to. 

The  method  of  maintaining  extension  has  also  been  a  ques- 
tion much  discussed,  and  fixed  extension  by  a  stirrup  attached 
to  the  end  of  the  Thomas  splints  has  been  commonly  adopted. 
Yet  in  a  large  number  of  cases  weight  and  pulley  extension  has 
been  preferred  and  is  sometimes  necessary.  The  question,  in 
fact,  has  not  been  settled  in  favor  of  either  of  vthe  opposing 
parties. 

A  third  method,  that  of  a  continuous  screw,  has  also  been 
considerably  employed,  both  in  conjunction  with  the  type  of 
Thomas  splint  with  a  spat  attachment,  in  the  Wallace-Maybury 
modification  of  the  Thomas,  and  also  in  the  bent  Thomas  splints 
and  their  modifications  for  treating  fractures  of  the  humerus 
with  the  elbow  flexed. 

The  use  of  the  pin  transfixing  either  the  lower  end  of  the 
femur,  or  the  upper  extremity  of  the  tibia,  for  the  attachment 
of  extension  apparatus  in  cases  of  fracture  of  the  femur,  has 
found  little  favor  in  France.  This  has  perhaps  mainly  depended 
'  on  unwillingness  to  make  a  fresh  wound  in  a  limb  already  the 
seat  of  a  septic  wound ;  but  beyond  this,  the  fact  that  practically 
all  patients  need  to  be  transported  at  an  earlier  date  than  would 


ABSTRACTS   OP    WAR   SURGERY  B5 

be  convenient  for  removal  of  the  pin  renders  the  method  unde- 
sirable. 

One  great  feature  in  the  wards,  and  an  incalculable  blessing 
to  the  patients  and  attendants,  has  been  the  wide  adoption  of 
the  overhead  rail  for  the  suspension  of  limbs,  and  to  take  the 
place  also  of  the  pulley  arranged  over  the  head  of  the  patient's 
bed  in  most  hospitals  to  allow  him  to  lift  himself  by  his  arms. 
This  was  devised  at  an  early  date  in  Boulogne  as  a  result  of 
seeing  patients  with  fractured  thigh  put  up  by  the  so-called 
Balkan  method  by  Lieutenant-Colonel  Miles.  It  has  consequently 
acquired  the  name  of  the  Balkan  support.  Two  of  them,  one 
placed  on  either  side  of  the  bed,  may  also  be  employed  for  the 
support  of  an  entire  hammock  bed. 

For  fixation  of  the  thigh  in  the  abducted  position,  the  abduc- 
tion frame  of  Kobert  Jones  was  ready  to  hand,  but  in  the  case  of 
the  upper  extremity  much  difficulty  was  experienced  in  the  earlier 
part  of  the  campaign  until  the  capability  of  a  short  Thomas  knee 
splint  for  this  purpose  was  fully  appreciated. 

A  great  amount  of  ingenuity  has  been  expended  on  splints 
devised  to  facilitate  transport  or  to  meet  special  emergencies, 
also  on  various  adjuncts  to  the  splints  themselves.  Thus  many 
varieties  of  rubber,  metal,  or  flannel  slings  to  support  tne  limbs 
in  wire  splints,  extension  attachments,  forms  of  glue  for  fixing 
extension  strips  to  the  limbs,  and  lastly,  the  highly  efficient  coun- 
terpoise suspension  apparatuses  of  Major  Sinclair.  Plaster  of 
Paris  has  on  the  whole  been  but  little  used,  and  mostly  for  the 
purposes  of  transport.  The  difficulty  of  keeping  plaster  splints 
clean  has  mainly  militated  against  them. 

Lastly,  as  to  the  treatment  of  the  wounds.  In  this  place  it  is 
assumed  that  proper  cleansing,  drainage,  and  removal  of  loose 
fragment  and  foreign  bodies  has  been  carried  out  at  the  casualty 
clearing  stations.  Under  these  circumstances  no  further  imme- 
diate procedures  are  needed  on  the  lines  of  communication.  Even 
in  the  case  of  inefficient  drainage  or  extending  infection  great 
judgment  must  be  exercised  in  interference  on  the  first  arrival 
of  the  patient. 

The  object  to  be  aimed  at  is  the  secondary  closure  of  the  wound 
at  the  earliest  date  practicable,  and  with  this  object  a  continuous 
antiseptic  method  should  be  carried  on.  Up  to  the  present  time 
the  most  conspicuous  success  in  this  direction  has  been  attained 
with  the  Carrel-Dakin  method,  and  if  treatment  has  been  com- 
menced at  the  casualty  clearing  station,  the  wound  may  in  a 


66  ABSTRACTS  OF  WAR  SURGERY 

considerable  proportion  of  all  cases  be  closed  within  a  period 
of  three  weeks. 

The  date  at  which  sequestra  should  be  removed  to  allow  a  com- 
plete surgical  sterilization  of  the  wound  has  raised  some  discus- 
sion. When  the  fracture  has  not  been  accompanied  by  sufficient 
loss  of  bone  for  risk  of  nonunion  to  occur,  there  can  be  no  doubt 
that  the  earliest  possible  date  is  desirable.  If,  on  the  other  hand, 
little  but  the  periosteum  and  a  few  fragments  remain,  the  prob- 
ability of  securing  a  sufficiently  active  osteogenesis  to  effect  union 
is  no  doubt  increased  by  leaving  apparently  dead  fragments  of 
bone  in  connection  with  the  periosteum  for  some  time,  because  a 
few  bone  cells  may  have  escaped  to  help  in  repair  which  will 
probably  perish  if  exposed  in  a  suppurating  wound. 

In  suppurating  fractures  of  some  standing  Rutherford  Mori- 
son's  method  of  secondary  closure  after  introduction  of  the 
iodoform,  bismuth,  and  paraffin  compound  has  been  imported 
from  England,  and  is  giving  good  results. 

Radical  treatment  for  the  condition  of  chronic  osteomyelitis 
has  not  often  been  undertaken,  unless  the  cases  are  of  such  a 
character  as  to  be  subjected  to  amputation;  the  majority  are 
transferred  to  England,  where  prolonged  stay  in  hospital  is  more 
readily  assured. 

Lastly,  methods  of  mechanical  fixation  by  plates  and  screws 
or  by  wiring  have  been  very  little  resorted  to  as  primary  meas- 
ures. A  very  large  proportion  of  the  cases  so  treated  failed  from 
the  septic  character  of  the  wound,  but  in  the  face  of  the  results 
more  recently  obtained  by  secondary  sterilization  and  closure 
of  the  wound  it  is  probable  that  these  methods  may  be  revived 
in  cases  of  difficulty  of  maintaining  the  fragments  in  position, 
or  at  any  rate  resorted  to  at  a  much  earlier  date  under  more 
favorable  conditions. 

Both  in  Boulogne  and  elsewhere  special  departments  have  been 
established  for  the  treatment  of  fractures  alone,  and  in  the  hos- 
pitals generally  an  attempt  has  been  made  to  collect  the  patients 
with  fractures  under  the  charge  of  one  medical  officer.  This 
plan  has  obvious  advantages  in  ensuring  special  aptitude  on 
the  part  of  the  surgeons  concerned  and  the  possibility  of  attain- 
ing general  results  approaching  the  ideal.  At  the  same  time,  its 
general  adoption  is  impracticable;  the  cases  are  of  a  nature  to 
necessitate  a  long  stay  in  hospital,  their  collection  in  one  ward 
imposes  a  very  heavy  task  on  the  nursing  staff,  which  needs  to 
be  largely  increased,  and,  finally  it  not  only  removes  a  source 
of  great  interest  from  the  general  surgeon,  but  it  also  renders 


ABSTRACTS  OF  WAR  SURGERY  67 

him  less  fit  to  treat  such  cases  when  heavy  fighting  produces 
them  in  such  great  numbers  as  to  render  segregation  impossible. 

Wounds  of  the  Joints. — The  experience  gained  in  recent  previ- 
ous wars  regarding  the  treatment  of  wounds  of  the  joints  has 
proved  of  small  avail  in  the  present  campaign,  because  it  was 
obtained  almost  entirely  from  observation  of  the  lesions  pro- 
duced by  rifle  bullets,  which  had  proved  themselves  of  minor 
gravity  and  capable  of  healing  spontaneously  with  good  results 
when  subjected  to  simple  treatment  founded  on  the  sovereign 
principle  of  rest. 

The  problem  of  dealing  with  grossly  infected  joints,  often 
enclosing  a  septic  irregular  fragment  of  shell  and  dirty  clothing, 
perhaps  further  complicated  by  extensive  fractures  of  the  can- 
cellous articular  extremities  of  the  bones,  was  therefore  prac- 
tically a  new  one  to  the  surgeons  engaged.  Some  definite  facts 
have  emerged  from  the  first  flood  of  difficulties  encountered,  and 
these  may  be  shortly  summarized  as  follows : 

1.  The  wound  of  the  soft  parts  clothing  the  joints  is  vastly 
more  difficult  to  deal  with  than  the  articular  cavity  itself,  and 
demands  the  most  scrupulous  care  on  the  part  of  the  surgeon. 

2.  The  synovial  capsule  itself  is  capable  of  dealing  unaided 
with  an  infection  often  of  a  really  serious  grade. 

3.  A  strong  tendency  exists  for  an  infection  to  localize  itself, 
and  the  remaining  portion  of  the  capsule  may  remain  free. 

4.  Drainage  in  the  sense  of  the  insertion  of  large  tubes  left  in 
position  for  days  or  more  is  not  only  useless  but  also  harmful. 

5.  That  a  gunshot  wound  of  a  joint  can  not  be  dealt  with  too 
early,  and  with  proper  treatment  forms  one  of  the  best  subject 
wounds  for  primary  suture. 

6.  That  following  the  primary  surgical  intervention  the  main 
principle  to  be  observed  is  that  of  complete  rest  gained  by  im- 
mobilization and  extension. 

General  appreciation  of  these  facts  has  resulted  in  the  con- 
clusion that  a  large  majority  of  the  joint  injuries  should  be 
subjected  to  their  chief  active  surgical  procedure  in  the  hospitals 
of  the  advanced  lines,  and  hence  the  general  hospitals  at  the 
present  time  receive  only  cases  well  upon  the  road  to  recovery,  or 
such  as  present  the  more  difficult  problem  of  dealing  with  estab- 
lished infection  and  suppuration. 

The  line  of  treatment  which  has  been  adopted  in  the  former 
class  of  case  has  been  already  laid  down  elsewhere  (June  2nd, 
p.  718)  ;  it  only  remains  to  add  that  even  cases  which  eventually 
do  excellently  often  arrive  on  the  lines  of  communication  with 


68  ABSTRACTS  OF  WAR  SURGERY 

synovial  effusion  and  local  redness  over  the  joint  and  in  the 
neighborhood  of  the  closed  wound,  signs  due  entirely  to  an  ex- 
acerbation consequent  on  the  disturbance  inseparable  from  trans- 
port down  the  lines.  Such  cases  usually  settle  down  rapidly  if 
only  strict  care  be  taken  to  maintain  complete  immobilization, 
while  any  premature  intervention  may  be  the  direct  cause  of 
disaster. 

The  class  of  case  may  be  first  dealt  with  in  which  a  patient 
arrives  with  a  foreign  body  still  occupying  the  joint  cavity.  This 
may  be  the  result  of  the  impracticability  of  early  x-ray  examina- 
tion, the  nature  of  or  the  small  size  of  the  foreign  body,  or  of 
a  large  number  of  patients  having  to  be  rapidly  dealt  with. 

If  the  foreign  body  be  a  rifle  bullet,  and  the  condition  of  the 
external  wound  satisfactory,  no  immediate  action  beyond  fixation 
of  the  joint  is  advisable  at  this  period.  It  is  far  safer  to  leave 
the  bullet  in  situ  until  all  chances  of  awakening  or  spreading 
an  infection  have  passed  by.  The  same  attitude  of  masterly 
inactivity  is  to  be  recommended  in  instances  in  which  the  included 
foreign  body  consists  of  very  small  fragments  of  shells  or  bombs, 
especially  if  the  bodies  lie  without  the  actual  confines  of  the 
articulating  surfaces.  Such  foreign  bodies  may  never  need  re- 
moval. Thirdly,  when  fragments  of  shell  are  of  larger  size  and 
need  removal  they  may  be  found  to  have  rebounded  from  the 
surface  of  the  bone  and  actually  lie  without  the  confines  of  the 
joint  cavity,  although  the  capsule  has  been  wounded.  Special 
care  needs  to  be  exercised  in  dealing  with  these  cases,  since  por- 
tions of  clothing  carried  before  them  by  the  shell  fragments  may 
still  occupy  the  joint  cavity.  Lastly  the  foreign  body  may 
be  impacted  more  or  less  deeply  in  the  articular  end  of  the  bone, 
and  if  a  shell  fragment,  it  should  be  removed,  although  in  a  pa- 
tient who  has  recently  undergone  transport  undue  haste  in  the 
procedure  is  not  advisable. 

Wounded  joints  which  arrive  with  obvious  local  and  general 
inflammatory  signs  need  to  be  treated  with  great  judgment.  The 
condition  may  have  been  aggravated  by  transport  and  may 
rapidly  improve  when  complete  rest  is  assured.  Again,  the  seri- 
ous infection  may  be  situated  in  the  periarticular  structures  rather 
than  in  the  joint  itself.  Precipitate  action  under  these  circum- 
stances is  to  be  deprecated.  The  safer  plan  is  to  place  the  limb 
at  rest  for  twenty-four  hours  or  longer,  and  observe  the  result, 
meanwhile  making  a  puncture  and  withdrawing  fluid,  if  present, 
for  bacteriological  examination.  If  want  of  improvement  or  the 
result  of  the  bacteriological  examination  indicate  the  advisability 


ABSTRACTS   OF   WAK    SURGERY  69 

of  intervention,  the  type  of  operation  should  be  of  the  nature 
advocated  by  Colonel  Gray — excision  of  the  wound  or  wounds 
in  the  joint  coverings,  flushing  of  the  synovial  cavity  after  evac- 
uation of  its  contents,  and  suture  of  the  synovial  membrane. 
The  treatment  of  the  external  wound  differs  according  to  its  size 
and  condition.  In  some  instances  it  may  be  closed  completely,  in 
others  a  drainage  tube  may  be  inserted  down  to  the  sutured  cap- 
sule, or,  where  the  wound  is  extensive  or  obviously  not  free  from 
infection,  it  is  better  to  leave  it  freely  open  and  treat  it  by  anti- 
septic measures  until  surgically  sterile  and  suitable  for  secondary 
suture.  Naturally  some  of  the  more  extensive  wounds  must  be 
left  to  heal  by  granulation. 

The  treatment  of  a  freely  suppurating  joint  requires  to  be  of 
a  different  character;  here  the  joint  cavity  must  be  maintained 
open  and  sterilization  effected  by  an  antiseptic  method,  of  which 
Carrel's  has  undoubtedly  given  the  best  results.  When,  for 
instance,  the  cavity  of  the  knee-joint  in  general  needs  to  be 
drained,  the  method  carried  out  by  Captain  Campbell  and  ad- 
vocated by  Captain  Gill  is  worthy  of  special  mention.  It  is 
generally  agreed  by  all  observers  that  when  suppuration  ex- 
tends backwards  from  the  knee  the  line  of  progress  is  not  from 
the  pouches  lying  on  either  side  of  the  crucial  ligaments  but 
around  the  lateral  aspects  of  the  condyles — in  point  of  fact,  by 
the  popliteus,  extension  of  the  capsule  on  the  outer  side  and  the 
semimembranosus  extension  on  the  inner.  Hence  posterior  drain- 
age from  the  center  of  the  joint  is  not  only  inconvenient  to  arrange 
but  also  inadequate  to  meet  the  requirements.  Posterolateral 
incisions  have  therefore  been  devised,  but  Campbell  and  Gill 
have  regularized  a  method  which  simplifies  greatly  the  accurate 
and  adequate  drainage  of  these  regions.  Lateral  incisions  having 
been  made  corresponding  in  position  with  the  reflection  of  the 
synovial  membrane  from  the  femur,  a  pair  of  artery  forceps  is 
pushed  down  on  the  outer  and  inner  aspects  of  the  lower  end  of 
the  femur  respectively  until  the  points  of  the  forceps  can  be 
palpated  in  the  popliteal  space.  An  incision  is  then  made  down 
on  the  guide  thus  furnished,  and  a  direct  route  is  established  to 
the  bursal  extensions  from  the  posterior  aspect  of  the  joint,  and 
by  this  Carrel's  tubes  are  conducted  for  the  requisite  depth. 
Should  still  freer  drainage  be  required,  the  incision  is  enlarged, 
the  respective  heads  of  the  gastrocnemius  exposed,  and  a  por- 
tion of  the  origins  of  the  muscle  excised,  so  that  a  free  opening 
is  insured.  Further  mention  of  the  treatment  of  the  extensions 
by  the  subcrural  pouch,  the  internal  intermuscular  septum,  be- 


70  ABSTRACTS  OF  WAR  SURGERY 

neath  the  popliteus  or  along  the  semimembranosus  tendon  is  un- 
necessary. The  upper  pouch  of  the  joint  may  need  several  in- 
stillation tubes,  which  are  gradually  decreased  in  number  and 
totally  removed  at  as  early  a  date  as  possible. 

For  suppurating  joints  of  some  standing  Rutherford  Morison's 
method  has  been  adopted  with  success. 

The  influence  of  a  coexisting  fracture  on  the  prognosis  in  a 
joint  injury  is  a  matter  of  great  moment  in  any  class  of  case,  but 
the  frequency  with  which  this  condition  is  met  with  in  gunshot 
wounds  invests  it  with  a  very  special  degree  of  importance. 

There  is  little  doubt  that  the  actual  risks  to  the  safety  of  the 
limb  attached  to  this  complication  were  somewhat  overestimated 
at  the  commencement  of  the  war,  and  that  today,  in  the  presence 
of  a  more  satisfactory  and  rational  treatment  of  the  wound,  and 
also  the  knowledge  acquired  as  to  the  possibility  of  saving  the 
joint  entire,  or  subjecting  it  to  either  primary,  intermediate,  or 
secondary  excision,  the  prospects  of  avoiding  amputation  are 
much  improved. 

It  may  be  laid  down  generally  that  tunnels,  cavities  contain- 
ing missiles,  fissures,  and  even  T-fractures,  do  not  of  necessity 
entail  a  very  serious  prognostic  gravity  provided  the  wound  in 
the  soft  parts  can  be  and  is  satisfactorily  dealt  with,  and  the 
fragment  of  shell  removed. 

In  a  large  proportion  of  such  injuries  a  more  or  less  movable 
joint  can  be  attained,  and  in  many  a  perfect  result.  Still,  in 
no  form  of  injury  does  this  more  depend  upon  the  continuous 
attention  of  the  surgeon,  care  in  the  initial  treatment  of  the 
joint,  and  subsequent  daily  precaution.  Injuries  affecting  both 
bony  elements  are  more  serious,  but  may  be  treated  by  excision. 
Severely  comminuted  articular  ends  commonly  need  amputation, 
except  where  the  single  articular  end  can  be  removed,  as  in  the 
case  of  the  upper  ends  of  the  humerus  and  femur,  or  where  bones, 
such  as  the  carpal  and  tarsal,  can  be  completely  removed.  The 
position  today  may  be  fairly  summed  up  by  the  remark  that, 
putting  on  one  side  articular  injuries  in  which  the  bony  de- 
struction is  irreparable,  the  fate  of  the  case  depends  upon  the 
success  with  which  the  wound  of  the  soft  parts  surrounding 
the  articulation  is  treated,  the  actual  joint  lesion  taking  a  place 
of  secondary  importance. 

Excision  of  Joints  for  Gunshot  Injury. — The  operation  of  ex- 
cision is  certainly  struggling  for  a  return  to  its  former  position 
as  a  procedure  in  military  surgery.  The  operations  were  no 
doubt  in  older  wars  often  performed  for  what  would  now  be 


ABSTRACTS   OF    WAR   SURGERY  71 

considered  injuries  not  sufficiently  extensive  to  demand  so  radical 
a  procedure ;  further  wound  treatment  was  often  defective.  Yet 
excision  occupied  a  prominent  place  until,  with  the  introduction 
of  the  bullet  of  small  caliber  and  oval  or  dome-shaped  tip,  in- 
juries of  the  joints  began  to  be  regarded  as  of  minor  importance. 

Early  Excision. — By  this  is  meant  immediate  operation  at  the 
casualty  clearing  station.  It  is  obvious  that  a  certain  number 
of  joints  may  be  excised  as  an  alternative  to  amputation.  Thus 
a  severe  localized  comminution  of  the  lower  end  of  the  femur  or 
the  upper  end  of  the  tibia  may  render  any  chance  of  recovery 
with  a  useful  limb  improbable,  while  the  uninjured  shaft  may 
still  be  of  sufficient  length  to  allow  of  ultimate  union.  The  same 
remark  may  apply  when  both  articular  surfaces  have  been  de- 
stroyed by  a  traversing  missile.  In  the  case  of  the  upper  end 
of  the  humerus,  and  also  of  the  femur,  comminuted  fractures  with 
destruction  of  the  articular  surface  also  form  good  subjects  for 
the  operation.  In  the  case  of  the  elbow  a  partial  excision  may 
often  be  done.  The  possibility  of  these  procedures  is  limited, 
however,  by  the  definite  condition  that  circumstances  will  allow 
the  patient  to  remain  a  sufficiently  long  time  to  be  able  to  bear 
safely  the  risk  of  transport  down  the  lines  of  communication 
to  the  general  hospital. 

Intermediate  Excision. — Concerning  this  operation  the  gravest 
doubts  were  felt  in  the  earlier  stages  of  the  war,  and  even  now 
it  can  be  undertaken  only  with  the  definite  intention  of  following 
it  at  once  by  an  amputation  if  the  procedure  is  followed  by 
local  extension  of  infection  and  signs  of  systemic  absorption. 
It  has,  however,  proved  that  excision  may  be  a  successful  alterna- 
tive when  the  severity  of  the  general  and  local  signs  seems  to 
indicate  amputation  as  the  only  resource.  The  explanation  of 
this  experience  can  be  found  solely  in  the  facts  that  better  drain- 
age can  be  insured  when  the  articular  ends  of  the  bones  have 
been  removed,  and  the  wound  can  be  treated  more  effectively. 
It  is  a  striking  fact  that  progressive  osteomyelitis  from  the  sawn 
ends  of  the  bone  has  not  developed,  especially  when  the  fre- 
quency of  this  complication  in  ill-drained  comminuted  fractures 
is  remembered.  Two  special  details  need  mention:  (1)  Should 
the  synovial  membrane  be  removed?  As  a  general  rule  this  ques- 
tion is  to  be  answered  in  the  negative.  The  synovial  surface  in 
itself  is  better  capable  of  dealing  with  an  infection  than  a  freshly 
cut  layer  of  subsynovial  areolar  tissue;  further,  when  no  ex- 
tensions of  suppuration  have  taken  place,  it  forms  an  effective 
barrier  against  such  extensions  when  proper  drainage  is  pro- 


72  ABSTRACTS  OF  WAR  SURGERY 

vided.  (2)  Should  the  refreshed  ends  of  the  bones  be  placed  in 
apposition,  or  be  temporarily  kept  widely  separated  by  exten- 
sion? The  latter  plan  has  been  most  generally  adopted.  The 
excision  of  bone  should  be  of  the  most  limited  extent  in  the  case 
of  the  knee.  Lastly,  in  this  joint  as  in  all  others,  excision  is  not 
to  be  regarded  as  a  proper  alternative  where  efficient  drainage 
can  be  expected  to  insure  the  end  desired. 

Late  Excision. — The  principles  guiding  the  performance  of  ex- 
cision at  a  later  date  do  not  materially  differ  from  those  laid 
down  above;  moreover,  as  far  as  the  hospitals  on  the  lines  of 
communication  are  concerned,  the  distinction  is  rather  one  of  date 
than  of  actual  pathological  conditions  to  be  dealt  with. 

The  Results  Obtained  in  Wounds  of  the  Knee-Joint. — In  HO 
consecutive  cases  of  knee-joint  injury  coming  from  the  fighting 
on  the  Somme,  14  were  classified  as  very  severe,  17  as  severe,  13 
as  slight,  and  16  as  having  retained  foreign  bodies.  Three  died 
and  one  required  amputation.  The  three  deaths  were  due  in  two 
cases  to  secondary  hemorrhage  and  in  one  to  septicemia.  The 
other  56  cases  were  transferred  to  England  in  good  condition, 
the  great  majority  with  every  prospect  of  good  movable  joints. 

In  a  second  series  of  69  cases,  in  31  the  injury  was  inflicted 
by  a  bullet,  and  in  all  an  uninterrupted  recovery  was  obtained 
by  rest  alone. 

Amongst  the  remaining  38  cases  one  died  as  a  result  of  menin- 
gitis following  a  fracture  of  the  skull,  and  in  four  cases,  one  of 
which  developed  delayed  tetanus  and  recovered,  amputation  was 
required. 

Thus  in  129  cases  amputation  was  required  in  3.87  per  cent, 
and  death  occurred  in  3.1  per  cent. 

Injuries  to  the  Head. — A  great  change  has  taken  place  since 
the  commencement  of  the  war  both  in  the  nature  of  the  cases 
and  in  their  actual  number.  This  change  depends  on  the  one 
hand  on  the  fact  that  a  larger  number  of  these  injuries  are  re- 
tained and  operated  upon  at  the  front  lines,  and  on  the  other  on 
the  protection  afforded  to  the  head  by  the  helmet.  The  early 
treatment  of  these  injuries  has  already  been  dealt  with ;  it  suffices 
here  to  say  that  the  patients  who  now  arrive  have  either  already 
been  operated  upon  and  are  in  good  condition,  or  they  come  down 
already  suffering  from  septic  complications.  The  general  lines 
governing  the  treatment  of  the  latter  class  of  case  have  been 
admirably  laid  down  in  a  paper  by  Sargent  and  Holmes  in  the 
British  Journal  of  Surgery,  and  certain  points  in  the  technic  of  the 
operative  procedure  elaborated.     These  authors  have  also  dealt 


ABSTRACTS  OF  WAR  SURGERY  13 

with  the  anatomical  and  histological  changes  associated  with  trau- 
matic injuries  and  infected  wounds  of  the  brain  and  their  bearing 
on  the  surgical  treatment  of  these  conditions.  Further,  exam- 
ination of  a  considerable  number  of  patients  some  months  after 
their  return  to  England  proved  much  more  satisfactory  than  had 
been  generally  expected.  It  was  found  that  the  proportion  of 
patients  who  die  after  transference  to  England  is  small;  later 
complications,  such  as  cerebral  abscess,  are  comparatively  rare, 
and  serious  sequelae,  such  as  insanity  and  epilepsy,  are  much  less 
common  than  had  been  foretold.  In  only  15  per  cent  of  the 
patients  examined,  however,  had  more  than  one  year  elapsed  from 
the  date  of  the  injury.  It  also  appeared  that  many  patients  with 
foreign  bodies  deeply  lodged  in  the  brain  recover,  and  are  scarcely 
more  liable  to  serious  complications  than  men  in  whom  the  brain 
has  been  merely  exposed  and  lacerated.  These  conclusions  are 
obviously  only  tentative,  but  as  far  as  they  go,  appear  to  be 
hopeful. 

Holmes  and  Sargent  have  also  described  a  condition  hitherto 
rarely  seen,  and  established  a  definite  symptom-syndrome  for  its 
recognition.  It  is  characterized  by  an  immediate  spastic  paralysis 
of  the  legs  and  frequently  associated  with  static  paresis 
of  the  proximal  segments  of  the  upper  limbs ;  they  have  shown  it 
to  be  due  to  occlusion  of  the  superior  longitudinal  sinus  of  the 
veins  that  enter  it,  by  a  depressed  fracture  of  the  vertex  of  the 
skull.  Experience  showed  the  results  of  surgical  interference 
with  cases  of  this  class  to  have  been  extremely  unsatisfactory. 
Thus,  among  39  cases  observed  which  were  operated  upon  either 
by  the  authors  or  others,  15  deaths  occurred,  while  among  37 
cases,  in  which  no  operation  was  undertaken  only  one  died  before 
transference  to  England.  While  it  is  allowed  that  these  figures 
have  no  absolute  value,  as  naturally  only  the  most  serious  cases 
were  selected  for  operation,  and  in  seven  of  the  fatal  cases  direct 
injury  to  the  brain  was  present  in  addition,  yet  the  results  empha- 
sized the  danger  of  operation.  Moreover,  the  uncomplicated  cases 
showed  a  remarkable  tendency  to  improve,  probably  owing  to  the 
free  venous  anastomosis  permitting  a  reestablishment  of  the  cir- 
culation. 

An  important  contribution  to  the  localization  of  function  in 
the  brain  has  been  published  by  Lister  and  Holmes,  who  from  a 
study  of  a  large  number  of  cases  with  injury  in  the  occipital 
region  were  able  to  determine  the  relative  positions  in  the  cor- 
tical visual  areas  of  the  foci  that  subserve  vision  of  separate 
portions  of  the  visual  fields.    They  bring  forward  strong  evidence 


74  ABSTRACTS  OF  WAR  SURGERY 

with  regard  to  the  site  for  the  center  for  macular  or  direct  central 
vision  of  which  very  little  had  been  previously  known. 
The  following  conclusions  are  come  to  : 

1.  The  upper  half  of  each  retina  is  represented  in  the  dorsal, 
and  the  lower  in  the  ventral,  part  of  each  visual  area. 

2.  The  center  for  macular  or  central  vision  lies  in  the  posterior 
extremities  of  the  visual  areas,  probably  on  the  margins  and 
the  lateral  surfaces  of  the  occipital  poles. 

3.  That  portion  of  each  upper  quadrant  of  the  retina  in  the 
immediate  neighborhood  of,  and  including  the  adjacent  part  of, 
the  fovea  centralis  is  represented  in  the  upper  and  posterior  part 
of  the  visual  area  in  the  hemisphere  of  the  same  side,  and  vice 
versa. 

4.  The  center  for  vision  subserved  by  the  periphery  of  the 
retinae  is  probably  situated  in  the  anterior  end  of  the  visual  area, 
and  the  serial  concentric  zones  of  the  retina  from  the  macula  to 
the  periphery  are  probably  represented  in  this  order  from  behind 
forwards  in  the  visual  area. 

Holmes  and  Smith  have  recorded  observations  on  the  nature 
and  localization  of  motor  apraxia,  or  the  inability  to  perform 
purposeful  actions  despite  the  preservation  of  movement  and 
power,  and  in  disturbance  of  the  faculty  of  localizing  objects  in 
the  external  world  by  vision. 

Probably  in  no  other  branch  of  medicine  have  so  many  and 
such  difficult  problems  arisen  as  in  the  treatment  of  wounds  and 
diseases  of  the  nervous  system.  Further,  in  this  field  an  extraor- 
dinary opportunity  has  occurred  to  observe,  analyze,  and  record 
the  effects  of  local  lesions,  many  of  which  are  rarely,  if  ever,  seen 
in  civil  life.  When  the  results  of  this  work  are  eventually  corre- 
lated, they  must  throw  much  light  on  the  physiology  and  the 
symptoms  of  disturbance  of  different  parts  of  the  brain,  spinal 
cord,  and  peripheral  nerves,  and  thus  increase  our  knowledge  of 
the  diagnosis  and  treatment  of  nervous  diseases.  Special  arrange- 
ments have  been  made  in  order  that  cases  under  early  observation 
in  France  should  be  sent  to  special  hospitals  in  England,  so  that 
continuous  records  will  be  maintained  of  a  very  large  number 
of  patients. 

Colonel  Percy  Sargent  adds  a  note  to  the  effect  that  the  very 
large  experience  gained  of  gunshot  wounds  of  the  head  has  led 
to  a  considerable  degree  of  modification  in  their  treatment.  Im- 
mediate routine  operation,  often  incomplete  and,  in  the  absence  of 
full  neurological  information  and  x-ray  examination,  sometimes 


ABSTRACTS  OF  WAR  SURGERY  75 

unnecessary  and  even  misdirected,  is  no  longer  widely  practiced. 
It  has  long  since  been  made  abundantly  clear  that  early  evacuation 
of  operated  cases  is  often  followed  by  disaster.  As  it  is  impossible 
to  operate  upon  these  cases  and  to  retain  them  at  the  clearing 
•stations  for  a  period  which  renders  transportation  safe,  more 
especially  during  times  of  great  military  activity.  The  practice 
now  generally  adopted  is  to  transfer  them  without  operation  as 
soon  as  possible  to  hospitals  further  down  the  line.  It  has  been 
made  quite  clear  that  surgical  intervention  is  rarely  required  for 
relief  of  cerebral  symptoms,  whether  general  or  local.  Its  chief 
aim  is  the  prevention  of  intradural  infection.  On  this  conception 
all  cases  of  gunshot  wounds  of  the  head  fall  into  one  or  two 
categories,  according  to  whether  the  dura  mater  has  or  has  not 
been  penetrated.  Nonpenetrating  wounds  have  a  low  rate  of  mor- 
tality, whether  operated  upon  or  not,  provided  that  the  surgeon 
respects  the  integrity  of  the  dura  mater. 

It  is  customary,  therefore,  to  do  in  these  cases  only  as  much 
as  may  seem  advisable  to  ensure  speedy  healing,  such  as  excision 
of  the  edges  of  the  wound,  removal  where  necessary  of  bony  frag- 
ments, and  partial  or  complete  closure  of  the  gap  in  the  scalp 
either  by  suture  or  by  some  form  of  plastic  operation. 

Penetrating  wounds,  on  the  other  hand,  afford  more  room  for 
difference  of  opinion  regarding  their  treatment.  Individual  cases 
continue  to  present  difficulties  even  to  those  who  have  seen  large 
numbers,  but,  broadly  speaking,  there  is  a  consensus  of  opinion 
in  favor  of  the  following  line  of  treatment :  The  wounds  having 
been  cleansed  and  dressed,  the  patient  is  transferred  as  soon  as 
possible  to  a  hospital  where  he  can  be  retained  for  at  least  a  fort- 
night after  the  operation.  A  complete  neurological  and  radio- 
graphic examination  is  made  and  the  operative  treatment  then 
directed  according  to  the  diagnosis  thus  arrived  at.  In  some  cases 
of  penetrating  wounds  no  operation  is  indicated,  such  as  those  in 
which  a  bullet  has  passed  completely  through  the  head ;  or  those 
in  which  a  bullet  or  a  metallic  fragment  is  embedded  in  the  brain 
at  a  distance  from  a  small  clean  entrance  wound,  and  is  giving 
rise  to  no  symptoms.  Another  class  of  case  for  which  operative 
interference  is  usually  contraindicated  is  that  in  which  the  longi- 
tudinal sinus  has  been  injured.  Cases  where  a  track  from  the 
scalp  wound  leads  down  to  indriven  bony  fragments,  or  to  an 
easily  accessible  missile,  are  operated  upon,  briefly,  as  follows: 
A  moderately  large  flap  is  turned  down  after  resection  of  all 
damaged  tissue  round  the  scalp  wound;  the  bony  opening  is 
enlarged  sufficiently  to  expose  thoroughly  the  opening  in  the  dura 


76  ABSTRACTS  OF  WAR  SURGERY 

mater ;  the  indriven  fragments  of  bone  and  metal  are  removed 
under  a  constant  stream  of  hot  physiological  saline  solution ; 
and  the  track  is  drained  by  a  celluloid,  metal,  or  rubber  tube 
brought  out  through  the  original  wound.  In  cases  of  more 
superficial  cerebral  laceration,  where  track  drainage  is  unneces- 
sary, the  principle  is  employed  of  covering  the  denuded  brain  by 
some  plastic  operation  on  the  scalp ;  in  these  circumstances  drain- 
age tubes  emerging  from  the  angles  of  the  scalp  flap  are  usually 
employed  for  a  few  days. 

Retained  Missiles. — Opinions  still  vary  regarding  the  advisa- 
bility of  operating  for  the  removal  of  bullets  or  shell  fragments. 
There  is  much  evidence  to  show  that  these  foreign  bodies  are  well 
retained,  and,  apart  from  the  uncommon  accident  of  late  sup- 
puration, cause  no  symptoms.  Removal  of  bullets,  even  when 
the  wounds  have  healed  and  the  risk  of  septic  infection  thereby 
is  largely  minimized,  must  be,  even  in  skilled  hands,  attended 
by  an  amount  of  damage  which  in  most  cases  would  have  more 
serious  neurological  consequences  than  could  the  presence  of  an 
aseptic  bullet.  Primary  removal  of  a  deeply-seated  missile  car- 
ries with  it  the  additional  risk  of  septic  infection. 

The  treatment  of  indriven  fragments  of  bone  is  more  debatable. 
When  driven  into  the  brain  by  a  missile  which  is  itself  retained, 
the  bony  fragments  are  rarely,  if  ever,  more  deeply  placed  than 
the  projectile.  When  driven  in  by  the  impact  of  a  missile  which 
does  not  itself  enter  the  cranial  cavity,  the  bony  fragments  are 
rarely  found  so  deeply  situated  but  that  they  can  be  removed 
along  the  tract  with  little,  if  any,  additional  damage  being  done. 

With  regard  to  the  septicity  of  these  indriven  metallic  and  bony 
fragments,  it  has  been  found  that  a  large  proportion,  when 
dropped  into  the  culture  media  immediately  upon  removal,  fail  to 
provoke  any  bacterial  growth,  either  aerobically  or  anaerobically. 

The  question  of  the  intracranial  pressure  has  been  the  subject 
of  repeated  observation.  Among  the  conclusions  of  practical  im- 
portance which  have  been  arrived  at  are  the  following : 

1.  Apart  from  the  rare  instances  of  extensive  intracranial 
hemorrhage,  traumatic  edema,  whilst  playing  an  important  part 
in  symptomatology,  does  not  reach  a  sufficient  degree  of  intensity 
to  endanger  life. 

2.  The  instances  of  severe  intracranial  hemorrhage  not  rap- 
idly fatal  are  very  few ;  and  even  amongst  these  there  is  a  certain 
number  which  surgical  intervention  is  not  likely  to  save.  Experi- 
ence has  shown  that  an  intracranial  hemorrhage  which  is  suffi- 
ciently severe   to   demand   operative   relief,   and  which   can   be 


ABSTRACTS  OF  WAR  SURGERY  77 

recovered  from,  gives  unmistakable  signs  of  its  progress.  The 
operation  can  be  deliberately  planned  and  carried  out  with  the 
definite  object  in  view.  Exploratory  operations  on  the  chance  of 
discovering  a  hemorrhage  are  rarely  if  ever  called  for. 

3.  In  case  of  intracranial  pressure  from  secondary  edema 
which  is  causing  severe  headache  and  herniation  of  brain,  this 
can  almost  always  be  controlled  by  lumbar  puncture.  Occasionally 
contralateral  decompression  has  been  done  for  these  eases  and  has 
afforded  good  results. 

Such  evidence  as  is  at  present  available  from  the  later  results 
(six  months  to  two  years)  is  all  in  support  of  the  general  policy 
of  treatment  outlined  above. 

The  steel  helmets  have  played  an  important  part.  The  study 
of  cranial  wounds  before  and  after  their  general  adoption  brings 
to  light  many  interesting  points.  The  outstanding  feature,  how- 
ever, is  that  which  concerns  the  penetration  of  the  dura  mater. 
The  proportion  of  penetrating  wounds  has  very  largely  dimin- 
ished, as  also  has  the  mortality,  another  amongst  many  indica- 
tions that  the  surgeon  can  not  attach  too  much  importance  to 
the  integrity  of  this  membrane,  or  treat  it  with  too  much  respect. 

Injuries  to  the  Spinal  Cord. — Wounds  and  injuries  of  the  spinal 
cord,  when  amenable  to  treatment,  demand  early  surgical  inter- 
vention. At  the  commencement  of  the  war  but  little  was  known 
regarding  the  actual  structural  changes  attendant  on  gunshot 
injuries,  and  what  was  known  was  concerned  mainly  with  the 
changes  which  were  found  in  spinal  cords  examined  at  a  compara- 
tively late  date.  The  position  of  the  surgeon  was  rendered  yet 
the  more  difficult,  in  that  past  clinical  experience  had  shown  the 
extreme  difficulty  which  exists  in  forming  a  correct  prognosis, 
particularly  in  view  of  the  remarkable  ultimate  recoveries  ob- 
served in  patients  whose  primary  symptoms  had  not  been  able  to 
be  distinguished  from  those  observed  as  attending  total  destruc- 
tive lesions. 

In  order,  therefore,  to  recognize  when  surgical  intervention 
can  be  undertaken  with  a  reasonable  prospect  of  success,  it  was 
necessary  to  obtain  an  accurate  idea  of  the  nature  of  the  patho- 
logical changes  produced  in  the  cord  by  modern  projectiles.  An 
investigation  on  this  subject  was  undertaken  by  Gordon  Holmes. 
He  found  that  even  slight  local  injuries  are  very  frequently  asso- 
ciated with  extensive  edema,  hemorrhages,  softenings,  and  often 
with  ascending  cavity  formation,  which  may  extend  a  consider- 
able distance  both  above  and  below  the  level  of  the  original 
injury  Or  wound.     These    changes    he    refers    to    the    concussion 


78  ABSTRACTS  OF  WAR  SURGERY 

effect  produced  by  the  missile  through,  the  walls  of  the  spinal 
canal;  they  may  exist  even  without  the  presence  of  a  fracture 
of  the  vertebrae.  Such  changes  can  obviously  not  be  relieved  by 
any  reasonable  operation,  and  the  fact  that,  apart  from  the  sec- 
ondary cavities  that  develop  later,  they  occur  immediately  or 
within  a  very  short  time  of  the  infliction  of  the  injury,  diminishes 
the  favorable  prospect  of  any  surgical  intervention.  In  some 
cases  undoubtedly  the  symptoms  are  largely  or  in  part  due  to 
compression  of  the  spinal  cord  by  either  the  missile  or  a  fragment 
of  depressed  bone,  but  numerous  examinations  have  proved  that 
even  in  these  the  same  intraspinal  lesions  exist.  Even  relatively 
slight  injuries  often  produce  for  the  first  few  days,  the  period 
when  operation  offers  the  best  chance  of  success,  symptoms  that 
may  be  confused  with  those  of  total  and  irreparable  damage  to 
the  cord,  and  some  clinical  indications  of  the  severity  of  the 
spinal  injury  is  consequently  necessary  before  an  operation  can 
be  reasonably  undertaken.  This  question  was  investigated  in  a 
large  number  of  cases  and  the  conclusions  were  published  in  the 
same  lectures.  These  are  to  the  effect  that  the  safest  guide  to 
the  severity  of  the  injury  is  afforded  by  the  form  and  character 
of  the  sensory  disturbances,  and  especially  by  the  changes  and 
modifications  in  the  reflexes  of  the  affected  limbs. 

In  most  cases  the  site  of  the  wound  or  radiographic  examina- 
tion permits  an  accurate  diagnosis  of  the  medullary  lesion,  but 
not  infrequently  this  can  be  determined  only  by  a  study  of  the 
symptoms  produced  by  it.  The  method  by  which  an  accurate 
local  diagnosis  can  be  made  is  also  dealt  with  in  these  lectures. 
Here,  too,  many  important  and  interesting  symptoms  which  result 
from  injuries  to  different  portions  of  the  spinal  cord  are  described. 
It  was  found,  for  example,  that  when  its  lower  cervical  and  the 
upper  thoracic  segments  were  severely  affected,  the  patients  often 
presented  a  serious  symptom-syndrome  characterized  by  hypo- 
thermia, bradycardia,  low  blood  pressure,  reduced  secretion  of 
urine,  and  mental  hebetude.  The  body  temperature  may  fall  as 
low  as  80°  F.  (27°  C),  the  pulse-rate  to  35  or  40  per  minute,  the 
blood  pressure  to  60  mm.  of  mercury,  and  only  4  to  8  oz.  of  urine 
may  be  secreted  in  the  twenty-four  hours. 

Injuries  to  the  region  from  which  the  vasomotor  fibers  to  the 
kidneys  pass  off  may,  on  the  other  hand,  produce  an  extraordinary 
polyuria,  and  lesions  in  the  higher  cervical  segments  were  shown 
to  be  often  associated  with  hyperpyrexia. 

The  acquisition  of  wider  knowledge  has  not,  however,  greatly 
widened  the  scope  of  operative  intervention.    Operations  are  still 


ABSTRACTS  OF  WAR  SURGERY  79 

for  the  most  part  confined  (1)  to  cases  in  which  a  radiographic 
or  direct  examination  reveals  the  presence  of  displaced  and  de- 
pressed fragments  of  bone  or  the  lodgement  of  foreign  bodies 
either  within  the  canal  or  buried  in  the  cord  (it  may  be  mentioned 
that  several  cases  have  been  observed  where  retained  bullets  have 
travelled  long  distances  within  the  spinal  canal,  particularly 
in  its  lower  part)  ;  (2)  to  cases  in  which  the  patients  suffer  severe 
and  unbearable  pain;  (3)  to  cases  in  which  pressure  from  hemor- 
rhage around  the  cord  is  suspected,  such  cases  being  very  rare. 
An  additional  class  may  be  added  in  which  a  late  operation  is 
performed  on  the  chance  of  some  improvement  being  gained, 
mainly  as  a  question  of  expediency.  Patients  with  injuries  to 
the  nerves  of  the  cauda  equina  have  as  a  rule  been  evacuated  to 
England. 

No  striking  change  in  operative  technic  has  been  developed, 
beyond  the  general  tendency  to  partial  rather  than  classical 
laminectomies,  and  perhaps  the  development  of  an  increased  con- 
fidence in  the  utility  of  placing  a  muscle  graft  over  the  opening 
in  the  spinal  membranes  when  leakage  of  cerebrospinal  fluid  has 
been  associated  with  the  performance  of  the  operation.  An  intact 
dura  has  throughout  been  an  important  immediate  prognostic 
element,  as  in  the  case  of  injuries  to  the  head. 

Early  drainage  of  the  bladder  by  a  suprapubic  tube  has  been 
advocated  by  Percy  Sargent  since  the  commencement  of  the  cam- 
paign, but  the  difficulties  in  the  transport  of  patients  thus  oper- 
ated upon,  and  the  increased  responsibility  devolving  on  the  nurse 
in  keeping  the  back  in  good  condition,  have  militated  against  an 
extensive  adoption  of  this  measure. 

Injuries  to  the  peripheral  nerves  have  been  extremely  common ; 
it  has  indeed  been  estimated  that  in  18  to  20  per  cent  of  all  limb 
wounds  slight  or  more  serious  lesions  of  the  large  nerve  trunks 
coexists.  But  owing  to  the  facts  that  when,  as  is  usually  the  case, 
extensive  septic  wounds  are  present,  the  early  surgical  treatment 
of  nerve  injuries  is  impracticable,  and  that  the  patients  with 
small  and  clean  wounds  can  be  safely  transferred  to  England, 
neither  the  treatment  nor  the  study  of  these  injuries  has  been  an 
urgent  question  in  the  general  hospitals  on  the  lines  of  commun- 
ication in  France. 

Abdominal  Injuries. — The  chief  interest  in  injuries  to  the 
abdomen  has  rightly  been  transferred  from  the  general  hospitals 
to  special  hospitals  at  an  advanced  line  or  to  the  highly  developed 
casualty  clearing  stations.  Prior  to  the  summer  of  1915,  however, 
the  great  majority  of  injuries  to  the  abdominal  viscera  were 


80  ABSTRACTS  OP  WAR  SURGERY 

dealt  with  on  the  expectant  system,  and  such  of  the  patients  as 
survived  arrived  in  the  general  hospitals.  The  experience  gained 
from  the  observation  of  these  afforded  some  information  regard- 
ing the  prognosis  of  wounds  of  both  hollow  and  solid  viscera, 
which  may  in  the  future  not  be  so  readily  obtained. 

The  enormous  mortality  attending  injuries  to  the  small  intes- 
tine was  clearly  demonstrated,  both  by  the  comparatively  small 
number  of  patients  arriving,  and  by  the  simple  nature  of  the 
injuries  found  at  postmortem  examination  compared  with  the 
extensive  and  multiple  character  of  the  lesions  which  have  been 
almost  uniformly  discovered  by  early  operations.  This  experi- 
ence exerted  a  healthy  influence  in  supporting  the  advisability 
of  early  operation.  The  lesser  fatality  attending  wounds  of  the 
colon,  excluding  the  transverse  colon  and  the  sigmoid  flexure,  was 
also  clearly  brought  out,  since  a  larger  porportion  of  wounds  of 
the  large  gut  arrived  at  the  general  hospitals,  and  of  these  more 
than  50  per  cent  recovered  sufficiently  to  be  transferred  to 
England  in  good  condition.  This  number  obviously  has  no 
bearing  on  the  actual  mortality  of  wounds  of  the  colon,  but  com- 
pared with  a  percentage  recovery  of  less  than  16  per  cent  in  a 
small  series  of  minor  injuries  to  the  small  intestine,  it  is  suffi- 
ciently striking. 

A  few  points  of  some  interest  also  emerged  from  the  series  of 
postmortem  examinations  made  on  patients  who  had  survived 
several  days,  thus  the  general  character  of  the  peritonitis  in  cases 
of  wounds  of  the  small  intestine,  and  the  localized  nature  of  that 
developing  in  consequence  of  wounds  of  the  large  intestine;  the 
observation  that  when  the  wound  tract  traversed  the  psoas  muscle 
and  its  sheath,  extravasation  of  fecal  contents  extended  to  the 
thigh,  and  indeed,  might  travel  the  whole  length  of  the  lower 
limb ;  that,  while  patients  dying  from  the  effects  of  wounds  of  the 
small  intestine  uniformly  succumbed  to  peritoneal  infection, 
deaths  following  wounds  of  the  colon  were,  in  40  per  cent  of  all 
the  cases,  the  result  of  a  general  infection  from  the  septic  wound 
of  the  soft  parts  of  the  trunk,  and  not  from  the  peritoneum  itself, 
the  main  feature  of  the  general  infection  being  a  purulent  bron- 
chitis; lastly,  in  a  series  of  postmortem  examinations  made  by 
Captain  Henry,  in  every  case  a  general  postmortem  invasion  of 
the  blood  stream  by  anaerobic  organism  was  discovered. 

Experience  again  proved  the  practical  futility  of  performing 
operations  for  the  closure  of  intestinal  wounds  after  thirty-six 
hours  has  elapsed  from  the  time  of  injury,  and  it  is  probable  that 
any  successes  obtained  in  this  field  can  be  counted  upon  the 


ABSTRACTS   OF    WAB    SURGERY  -  I 

fingers.  On  the  other  hand,  the  good  results  often  obtained  by 
performing  a  proximal  colostomy  in  large  wounds  involving  the 
colon,  and  thus  preventing  the  occurrence  of  the  late  systemic 
infection  referred  to  above,  have  been  amply  proved.  The  few- 
cases  in  which  an  attempt  has  been  made  to  obtain  the  same  result 
by  making  an  intestinal  short  circuit  by  anastomosis  have  not  been 
encouraging,  and  it  is  obvious  that  this  class  of  case  is  not  a 
favorable  one  for  such  procedure,  both  by  reason  of  the  general 
condition  of  the  patient  and  the  difficulty  in  performing  a  clean 
operation. 

No  novel  features  have  been  disclosed  by  observation  of  the 
numerous  instances  of  wounds  to  the  solid  abdominal  viscera, 
except  that  perhaps  more  attention  has  been  given  to  interference 
with  their  secretory  activity,  and  that  the  favorable  course 
commonly  following  these  injuries  in  the  absence  of  serious  septic 
complications  has  tended  to  confirm  the  propriety  of  maintaining 
an  expectant  attitude  in  the  question  of  surgical  intervention. 
Speaking  generally,  it  may  be  said  that  the  formation  of  an 
abscess  or  the  occurrence  of  secondary  hemorrhage  are  the  only 
indications  for  interference  at  the  period  at -which  the  patients 
reach  the  general  hospitals.  Septic  infection  has  been  the  common 
cause  of  death  in  all  cases  of  fatal  injury  to  the  solid  viscera, 
and  in  40  per  cent  of  deaths  from  wounds  of  the  liver  second- 
ary hemorrhage  has  accounted  for  the  fatal  issue. 

Intraperitoneal  injuries  to  the  urinary  bladder,  even  discovered 
during  operation,  have  been  rare  throughout  the  campaign,  and 
for  some  reason  probably  connected  with  the  conditions  of  trench 
warfare  extraperitoneal  wounds  have  been  far  less  often  seen 
than  in  the  earlier  stages  of  the  war.  These  latter  cases  were  the 
source  of  much  interest  because  they  were  sometimes  difficult 
to  diagnose  from  injury  to  the  small  intestine  in  the  early  stage, 
and  also  because  treatment  by  simple  suprapubic  cystostomy 
was  found  so  successful.  Of  thirty  such  consecutive  operations 
only  two  proved  unsuccessful,  and  in  each  of  these  comminuted 
fractures  of  the  pelvis  were  coexistent.  If  treated  expectantly, 
in  many  instances  the  urine  escaped  freely  from  apertures  in  the 
abdominal  wall,  the  buttock,  or  the  thigh  for  a  week  or  ten  days, 
and  the  patients  appeared  to  be  doing  well,  when  infection  of 
the  urine  took  place,  extended  to  the  bladder,  and  toxemia  fol- 
lowed. Even  in  the  latter  class  of  case,  however,  a  late  operation 
may  save  the  patient. 

The  condition  of  cases  arriving  at  the  general  hospitals  sub- 


82  ABSTRACTS  OF  WAR  SURGERY 

sequently  to  the  primary  operations  at  the  advanced  lines  deserves 
a  word  of  mention,  although  the  patients  are  for  the  most  part 
birds  of  passage. 

The  general  results  have  been  remarkably  good,  the  most  com- 
mon defect,  now  not  so  common  as  in  the  earlier  stages  of  the 
adoption  of  early  operation,  has  been  incomplete  union  of  the 
wound  in  the  abdominal  wall.  In  some  cases  this  has  been 
accounted  for  by  a  primary  use  of  the  initial  entry  or  exit  aper- 
ture for  the  site  of  exploratory  incision,  in  others  from  the  per- 
sistency of  a  gap  left  for  a  drainage  tube;  but  beyond  these 
complicating  factors,  an  obvious  difficulty  has  been  experienced 
in  obtaining  firm  primary  union.  In  some  cases  this  may  have 
depended  on  an  actual  deficiency  in  vitality  of  the  patient,  but 
in  the  majority  it  has  undoubtedly  been  due  to  infection,  and 
when  it  is  borne  in  mind  that  these  operations  are  performed  on 
the  subjects  of  intestinal  perforations  in  whom  infected  blood 
is  present  and  has  to  be  evacuated  from  the  abdominal  cavity, 
it  is  not  to  be  wondered  at.  Such  wounds  have  usually  healed 
readily  by  granulation.  The  next  occasional  trouble  has  been 
the  secondary  formation  of  abscesses  or  fistulse.  These  have 
not  been  common,  the  abscesses  usually  following  colic  wounds 
and  the  fistulae  wounds  of  the  small  intestine.  It  is  noteworthy 
that  fistulas  have  formed  secondarily  in  several  cases  in  which  the 
primary  exploration  has  been  negative — a  fact  bearing  on  the 
common  occurrence  of  severe  contusion  of  the  wall  of  the  intestine 
unaccompanied  by  perforation.  As  a  rule,  the  bowels  have 
acted  regularly  and  well;  in  some  instances  diarrhea  has 
been  troublesome,  and  the  writer  has  only  seen  one  patient  in 
whom  secondary  obstruction  was  caused  by  adhesions.  On  the 
whole,  the  evidence  seems  against  troublesome  peritoneal  adhe- 
sions developing  with  any  degree  of  frequency.  In  one  post- 
mortem examination  made  upon  a  patient  who  died  from 
pneumonia  the  abdominal  cavity  was  absolutely  free  from  adhe- 
sions, and  an  end-to-end  anastomosis  was  so  perfect  as  to  be  with 
difficulty  discovered.  As  is  usually  the  case,  however,  the  bowel 
on  the  proximal  side  of  the  line  of  union  was  already  somewhat 
dilated. 


WOUND  INFECTION  AND  TREATMENT. 

GUNSHOT  WOUNDS  AND  THEIR  TREATMENT.— Sir  Berke- 
ley Moynihan.    Surg.,  Gyn.  and  Obstet.,  December,  1917. 

Surgeons  who  were  responsible  in  the  early  weeks  of  the 
present  war  for  the  treatment  of  the  wounded  soldiers  com- 
ing home  from  France  are  never  likely  to  forget  their  experience. 
There  were  wounds  of  many  dimensions  and  of  every  tissue,  all 
characterized  by  the  most  profuse  and  offensive  suppuration.  A 
challenge  was,  so  to  say,  thrown  to  the  profession,  which  we  may 
now  with  due  modesty  claim  has  been  splendidly  and  trium- 
phantly met.  Rebukes  and  taunts  at  our  incompetence  were  not 
seldom  heard  in  those  far  off  days.  We  are  asked  if  Lister  had 
worked  in  vain;  we  were  told  we  had  failed  to  learn  the  lesson 
he  had  spent  his  life  in  teaching. 

It  is  interesting  to  read  again  the  works  of  Lister,  and  to  see 
how  helpless  he  felt  himself  in  dealing  with  putrefactive  pro- 
cesses once  firmly  established  in  a  wound.  Lister  everywhere 
distinguishes  between  the  "prophylactic"  and  the  "therapeutic" 
uses  of  antiseptics.  All  the  marvelous  achievements  of  modern 
surgery  are  due  to  the  adoption  by  surgeons  the  whole  world 
over,  of  the  principle  of  the  prevention  of  infection  in  wounds 
about  to  be  made  as  distinguished  from  that  of  the  subduing  of  an 
infection  already  rampant. 

Lister  writes :  ' '  The  original  idea  of  the  antiseptic  system  was 
the  exclusion  of  all  microbes  from  wounds."  Again,  "During 
the  operation,  to  avoid  the  introduction  into  the  wound  of  mate- 
rial capable  of  inducing  septic  changes  in  it,  and  secondly  to  dress 
the  wound  in  such  manner  as  to  prevent  the  subsequent  entrance 
of  septic  mischief."  Again,  "In  wounds  already  septic  attempts 
are  made  with  more  or  less  success  to  restore  the  aseptic  state." 
Again,  "In  speaking  of  the  antiseptic  system  of  treatment,  I 
refer  to  the  systematic  employment  of  some  antiseptic  substance 
so  as  entirely  to  prevent  the  occurrence  of  putrefaction  in  the 
part  concerned,  as  distinguished  from  the  mere  use  of  such  an 
agent  as  a  dressing." 

The  distinction  between  the  preventive  and  the  curative  use 
of  antiseptics  is  in  many  respects  that  existing  on  the  one  hand 
between  the  power  of  a  germicide  as  determined  by  experiments 

83 


84  ABSTRACTS  OF  WAR  SURGERY 

in  vitro,  and  on  the  other  hand,  its  capacity  to  destroy  organisms 
when  it  is  introduced  among  the  living  and  the  dead  tissues  of  a 
wound.  In  the  former  there  is  a  direct  conflict,  a  clean  fight, 
between  the  microbe  and  the  chemical  agent.  Few  or  none  of 
the  many  intervening  conditions  are  present  which  have  to  be 
considered  when  a  bactericide  is  introduced  into  a  wound  cavity 
wherein  there  are  a  multitude  of  actions  and  reactions  which 
even  now  seem  very  obscure  and  are  so  often  conflicting. 

When  after  the  lapse  of  many  weeks  from  the  outbreak  of  war, 
there  came  a  full  appreciation  of  the  several  circumstances  which 
had  to  be  reckoned  with  when  a  soldier  was  wounded,  it  was 
recognized  on  all  hands  that  a  new  and  grave  problem  had  arisen 
which  cried  urgently  for  solution.  What  then  were  the  several 
new  factors  that  had  to  be  considered? 

In  the  early  days  a  very  large  number  of  the  wounds  were 
inflicted  by  rifle  fire.  The  German  bullet  has  a  muzzle  velocity 
of  approximately  1000  yards  per  second.  In  the  first  800  yards 
or  thereabouts,  the  flight  of  the  bullet  is  not  steady  but  "wob- 
bling. ' '  There  are  three  movements :  a  movement  forward  along 
the  line  of  flight ;  a  rotary  movement,  in  which  the  bullet  spins 
round  on  its  longitudinal  axis  as  a  result  of  the  "rifling"  of  the 
barrel;  and  a  third  movement,  a  mouvement  de  bascule  of  such 
a  character  that  while  the  point  of  the  bullet  keeps  steady  the 
base  of  the  bullet  is  moving  round  a  circle,  or  an  ellipse,  of  a 
gradually  diminishing  size.  The  result  of  the  last  form  of  motion 
is  this,  that  when  the  bullet  impinges  upon  any  substance,  even 
the  soft  clothing  or  the  flesh,  the  infinitely  brief  arrest  of  the 
point  which  strikes  first,  allows  the  base,  which  is  of  course  much 
heavier,  to  overtake  the  apex,  and  the  bullet  then  lies  sidewise  or 
begins  to  turn  over  and  over  as  it  ploughs  its  way  through  the 
soft  parts.  In  this  early  part  of  the  trajectory  the  missile  has, 
of  course,  a  great  momentum ;  it  is  a  heavy  bullet  travelling  with 
great  velocity.  The  consequence  is  that  the  damage  inflicted  is 
not  confined  to  the  track  it  rudely  makes  through  the  limb :  the 
parts  around  the  track  are  damaged  also,  often  to  a  great  extent, 
and  microbes  are  driven  deeply  into  all  adjacent  tissues.  Every 
wound,  therefore,  caused  by  a  bullet  at  short  range,  consists 
not  only  in  a  visible  tearing  and  destruction  along  the  path  the 
bullet  has  followed,  but  in  a  dead  zone  everywhere  surrounding 
that  track.  And  even  that  is  not  all.  The  momentum  of  the 
bullet  is  such  that  to  everything  it  encounters  it  imparts  some  of 
its  own  velocity.    As  we  all  know,  shreds  of  the  clothing  or  belt, 


ABSTRACTS  OF  WAR  SURGERY  85 

or  the  contents  of  the  pocket,  may  be  carried  deeply  into  a  wound. 
So  also  are  pieces  of  skin  or  muscle.  And  if  the  bullet  should 
chance  to  strike  a  bone,  the  bone  is  not  only  broken  into  many 
fragments,  the  "splinter"  fracture,  but  to  all  fragments  there 
is  conveyed  enough  of  the  momentum  of  the  bullet  to  convert  them 
into  projectiles  also,  capable  of  tearing  a  way  into  the  softer 
tissues.  Many  of  the  wounds,  therefore,  were  deep,  irregular  in 
shape,  with  large  or  small  cavities.  Into  these  recesses  blood 
escapes,  and  owing  to  the  tearing  and  unequal  retraction  of  cut 
muscles,  pools  of  fluid  may  be  shut  off  from  the  main  track  of  the 
wound,  and  form  an  ideal  breeding  ground  for  all  microorganisms, 
especially  those  which  are  anaerobic. 

If  a  rifle  bullet  is  not  checked  in  the  first  600  yards  of  its 
flight,  it  begins  to  steady  down,  and  probably  when  it  has  travelled 
1,000  yards  it  is  moving  evenly.  An  injury  inflicted  then  is  of 
a  quite  different  character.  The  bullet  cleaves  its  way  through 
the  soft  parts,  bores  a  neat  hole  through  a  bone,  and  little  des- 
truction is  done.  We  see  many  cases  where  the  chest  or  abdomen 
are  traversed  from  side  to  side,  or  where  the  neck  has  been 
pierced,  and  miraculously,  no  real  damage  has  been  done. 
Examples  of  this  form  of  injury  were,  of  course,  common  enough 
in  the  South  African  War.  They  have  been  less  frequent  in  this 
war  because  the  range  has  often  been  shorter,  and  the  bullet  in 
respect  to  velocity  and  weight  is  different. 

During  the  last  two  years  a  very  large  proportion  of  these 
wounds  have  been  inflicted  by  shrapnel  bullets,  hand  grenades, 
or  shell  casing.  The  immense  velocity  of  the  projectiles,  espe- 
cially when  a  high  explosive  shell  bursts,  their  irregular  shape, 
their  pitted  surface  and  sharp  edges,  all  combine  to  cause  wrounds 
of  very  diverse  forms.  The  track  is  a  distorted  one,  the  parts 
around  it  are  bruised  and  battered  or  dead,  and  the  infection 
carried  into  the  wound  by  a  piece  of  metal  or  cloth  has  unre- 
stricted opportunities  of  spreading  rapidly.  In  many  cases 
large  areas  of  the  limbs  or  trunk  are  blown  away.  The  wound 
remaining  shows  a  shattered  and  irregular  surface ;  the  muscles 
are  torn  and  crushed,  or  "pulped"  and  lose  their  structure.  They 
dry  rapidly  on  exposure  and  therefore  fall  easy  victims  to  a 
bacterial  attack  often  of  great  ferocity. 

The  condition  of  the  battlefields  of  Flanders  and  of  France 
accounts  for  the  quality  of  the  infective  agents.  Many  parts  of 
the  lands  over  which  the  fighting  has  taken  place,  both  before 
and  since  trench  warfare  set  in,  were  cultivated  assiduously  by 


86  ABSTRACTS  OF  WAR  SURGERY 

the  rural  inhabitants  before  the  war.  Probably  no  soil  in  Europe 
has  been  more  liberally  manured  in  efforts  at  intensive  cultiva- 
tion. Certainly  no  contact  between  the  soldier  and  the  soil  has 
ever  been  more  intimate  or  more  protracted.  Every  projectile 
passing  through  the  garments  to  the  body  will  certainly  be  cov- 
ered with  the  mud  or  dust  in  the  clothes,  and  with  the  many 
organisms  that  a  respite  from  ablutions  has  allowed  to  penetrate 
the  skin.  All  bacteriologists  and  surgeons  are  now  agreed  that 
no  influence  perpetuating  infection  in  a  wound  is  so  malign  as 
that  which  is  harbored  in  the  torn  fragments  of  clothing.  The 
physical  condition  of  the  soldier  himself,  when  he  is  wounded, 
no  doubt  plays  an  important  part  in  exalting  the  virulence  of 
any  infection  which  may  settle  upon  him.  Though  in  the  best 
of  health  and  physical  condition  at  the  moment  of  attack  he  may, 
by  the  time  he  is  wounded,  have  suffered  great  fatigue,  and  bleak 
exposure,  for  hours,  or  even  days,  before  succor  comes  to  him. 
The  organization  for  the  collection  and  dispatch  to  the  field  am- 
bulances and  casualty  clearing  stations,  of  wounded  men  is  prob- 
ably as  perfect  as  any  endeavor  can  make  it.  But  there  are 
times,  especially  in  a  "push"  when  a  man  may  lie  out  undis- 
covered for  long  periods.  Not  infrequently  by  reason  of  such 
causes,  and  on  account  of  pain  and  hunger  and  loss  of  blood  he 
may  be  reduced  to  a  state  in  which  his  power  of  resistance  to 
a  bacterial  attack  is  greatly  impoverished. 

Bacteriology. — The  bacteria  infesting  the  wounds  in  France 
have  been  studied  by  Wright,  Fleming,  and  others.  The  general 
conclusion  drawn  from  their  work  is  that  the  microorganisms,  as 
might  be  expected,  are  those  found  in  highly  manured  soil;  they 
are,  that  is  to  say,  of  fecal  origin.  Wright  suggests  the  new  names 
' '  serophytes ' '  for  those  organisms  which  will  grow  in  normal  serum, 
streptococci,  and  staphylococci;  and  " serosaprophytes "  for  those 
which  can  only  grow  in  digested  albumens.  The  native  albumens 
of  human  serum  are  "protected"  from  bacterial  development  at 
their  expense,  and  Wright  points  out  that,  if  this  were  not  so, 
human  life  would  have  been  impossible.  Among  the  serosapro- 
phytes are  the  larger  number  of  the  organisms  found  in  wounds,  in- 
cluding all  the  anaerobes;  the  bacillus  of  Welch,  the  bacillus  of 
tetanus,  the  enterococcus,  a  streptococcus  of  intestinal  origin  de- 
scribed by  the  French,  the  bacillus  coli,  and  putrefactive  bacilli 
X  and  Y,  which  are  the  cause  of  the  foul  odor  often  met  with  in 
wounds.  There  is  often  a  "wisp"  bacillus,  and  a  diphtheroid 
bacillus  appears  in  later  stages  of  the  infection. 

All  these  microorganisms  find  a  most  fertile  medium  for  their 


ABSTRACTS  OF  WAR  SURGERY  87 

growth  in  wounds  of  the  character  described.  In  every  wound, 
where  the  recesses  are  many  and  intricate,  blood  or  serum  may 
be  poured  out;  tryptic  digestion  begins  as  a  consequence  of  the 
destruction  of  the  leucocytes,  peptones  are  formed  and  bacteria, 
finding  everything  to  their  liking,  grow  apace.  From  many  of  the 
wound  surfaces  the  circulation  has  been  cut  off  by  the  powerful 
stunning  effect  of  the  blow  given  by  the  projectile,  and  gangrene 
and  sloughing  make  haste  to  develop.  During  the  first  four  to 
six,  or  in  some  cases  even  eight  hours,  few  organisms,  or  none,  can 
be  recovered  from  the  wounds,  either  by  smear  methods  or  by 
cultural  methods.  The  organisms  are  there  nevertheless,  and  given 
the  prodigal  fertility  of  the  soil  in  which  they  are  sown,  will  quickly 
show  the  evidence  of  their  growth.  In  this  brief  early  period  the 
wound  is  said  to  be  "contaminated,"  in  all  later  periods  "in- 
fected." 

The  chief  defense  is  in  the  blood  serum  and  in  the  leucocytes 
(phagocytes).  The  capacity  of  these  two,  if  only  they  have  an 
adequate  chance,  may  be  said  to  be  almost  illimitable  against  all 
organisms  but  the  streptococcus.  The  serum  possesses  strong  bac- 
tericidal powers  of  its  own;  the  phagocytes  can  devour  bacteria 
greedily.  But  in  exerting  their  powers,  both  serum  and  white 
cells  are  apt  to  undergo  degradation.  The  leucocyte  breaks  down 
and  its  power  of  tryptic  digestion  is  then  exerted  upon  the  fluids 
around  it,  and  peptones  are  produced  in  quantities  which  make 
easy  the  growth  in  them  of  all  forms  of  bacteria.  Moreover,  the 
surface  of  the  wound  soon  becomes  "lymph-bound."  A  mesh  of 
fibrin  entangles  the  blood-cells,  and  a  sort  of  matting  of  coagulated 
lymph  spreads  over  all  the  surface.  No  fresh  serum  can  then 
reach  the  wound,  nor  are  fresh  leucocytes  available  for  the  attack. 
The  infective  process  can  then  proceed  apace,  unhindered  by  those 
powerful  natural  defenses  which  for  the  moment  have  quite  broken 
down. 

The  Principles  and  Methods  of  Treatment  of  Gunshot  Wounds. 
— (a)  Primary  Closure. — Everyone  to  whose  lot  it  has  fallen  to 
undertake  the  surgical  treatment  of  wounds  in  this  war  will 
agree  that  the  most  urgent  need  is  to  secure  their  complete 
closure  at  the  earliest  possible  moment.  In  the  early  hours,  dur- 
ing the  period  of  "contamination,"  it  is  now  the  common  prac- 
tice to  excise  freely  all  damaged  and  dead  tissue  if  possible  in 
one  piece.  This  requires  some  skill  and  no  little  practice  to  do 
excellently.  The  most  careful  preparation  of  the  skin  and  the 
parts  around  the  wound  is  a  necessary  antecedent  to  any  operative 
measures.    The  wound,  of  whatever  type,  is  excised  together  with 


OO  ABSTRACTS  OF  WAR  SURGERY 

a  wall  not  less  than  one-third  inch  around  it.  In  order  to  make 
certain  that  all  the  walls  of  the  original  wound  are  excised, 
Wilson  Hey  has  suggested,  and  has  long  employed,  a  method  of 
staining  with  brilliant  green,  which  is  injected  into  all  parts 
of  the  wound  and  allowed  to  remain  not  less  than  two  minutes. 
The  staining  of  a  wound  not  only  makes  a  more  thorough  removal 
possible,  but  it  also  indicates  those  parts  which  can  not,  or  may 
not,  be  removed,  to  which  therefore  a  simple  mechanical  cleansing 
must  be  more  particularly  directed.  The  walls  of  the  cavity 
remaining  after  excision  should  bleed  everywhere ;  perfect  hem- 
ostasis  is  then  secured.  Every  soiled  instrument  or  glove  is  at  once 
discarded.  The  wound  may  then  be  stitched  up  completely  with- 
out drainage,  and  with  much  confidence  may  be  expected  to  heal 
well.  The  cases  coming  to  the  base  hospitals  in  England  show 
that  in  a  great  variety  of  injuries  this  method  of  the  primary 
closure  of  wounds  is  meeting  with  a  very  remarkable  success. 
If  the  operation  is  carried  out  with  scrupulous  exactitude  and 
with  something  near  to  technical  perfection  in  cases  of  "con- 
taminated" wounds,  probably  not  less  than  90  per  cent  will  heal 
by  first  intention.  The  failure  occurs  in  those  cases  where  a 
piecemeal  removal  of  the  infected  wall  has  been  carried  out, 
where,  that  is  to  say,  there  has  been  frequent  reinfection  of  the 
newly  made  raw  surfaces. 

There  has  been  in  all  armies  a  certain  timidity,  very  natural, 
and  perhaps  from  many  points  of  view  very  desirable,  in  carry- 
ing out  the  method  of  primary  closure.  No  one  who  has  worked 
even  for  a  brief  period  in  the  armies  in  France  can  have  failed 
to  realize  the  desperately  serious  results  which  come  from  the 
injudicious  closure  of  septic  wounds.  Gas  gangrene,  for  example, 
may  develop  in  an  amputated  stump,  if  even  one  stitch  is  put 
in  to  approximate  the  flaps.  And  there  has  consequently  sprung 
up  on  all  sides  a  fear  of  the  premature  closure  of  wounds.  But 
recent  experience  would  seem  to  show  that  at  least  in  the  early 
cases,  in  cases  reaching  a  well-equipped  surgical  unit,  say  within 
8  or  10  hours,  in  the  period  of  contamination  rather  than  a  spread- 
ing infection,  a  mechanical  cleansing  of  the  most  thoroughgoing 
kind,  carried  out  ruthlessly  and  rapidly,  will  allow  the  great 
majority  of  the  cases  to  be  closed  with  an  excellent  chance  of 
primary  union.  There  can  no  longer  be  any  doubt  that  many 
of  the  cases  which  have  proved  so  successful  under  the  Carrel- 
Dakin  method,  applied  during  the  first  6  to  8  hours,  would  have 


ABSTRACTS  OF  WAR  SURGERY  89 

closed  equally  safely,  and  far  more  rapidly,  under  the  method 
of  immediate  suture ;  and  that  consequently  a  certain  degree  of 
suffering  and  much  expenditure  of  time  and  no  little  expense 
would  have  been  saved.  To  put  this  statement  in  what  may  seem 
an  extreme  fashion,  it  may  be  said  that  the  Carrel-Dakin  method 
has  achieved  its  greatest  triumphs  in  cases  where  it  need  not 
in  fact  have  been  applied.  But  if  this  opinion  is  true  it  must 
at  once  be  admitted  that  one  of  the  chief  experiences  which  have 
led  to  its  realization  is  the  practice  of  this  method,  with  great 
success  during  many  months.  More  than  ever  are  we  now  con- 
firmed in  our  strong  opinion  that  it  is  the  primary  mechanical 
cleansing,  after  thorough  exposure,  and  with  every  precaution 
and  care,  that  is  the  supreme  necessity  in  all  cases ;  and  that  this 
alone,  if  complete,  will  allow  the  natural  defenses  of  the  body  to 
secure  the  blameless  healing  of  the  wound.  In  doubtful  cases, 
indeed  in  any  case,  a  small  drain  of  a  few  strands  of  silkworm-gut 
may  be  left  in  the  corner  of  a  wound  closed  by  primary  suture. 
All  cases  are  watched  carefully  for  a  few  days.  If  the  tempera- 
ture remains  high,  or  if  the  wound  on  being  uncovered  looks 
angry,  inflamed,  and  especially  if  a  streptococcus  infection  is 
found,  the  wound  must  be  opened  up  completely  and  treated  by 
one  of  the  methods  to  be  presently  described. 

(b)  Secondary  Closure. — If,  however,  owing  to  one  or  more 
among  a  great  diversity  of  circumstances,  the  patient  arrives  at 
a  base  hospital  with  a  freely  suppurating  wound,  the  problem  is 
quite  different.  The  chance  of  primary  closure  has  passed  away 
perhaps  long  ago ;  the  wound  now  may  be  covered,  sparsely  or 
thickly,  with  sloughs  of  varying  size,  and  in  various  stages 
of  detachment.  Layers  of  lymph  adhere  at  one  point,  or  at  many, 
to  the  wound  surface,  and  the  discharges  are  thick,  purulent,  and 
offensive.  The  problem  here  is  first  to  secure  a  healthy  and  rela- 
tively uninfected  surface,  and  secondly  to  close  the  wound  by 
suture  on  the  earliest  prudent  occasion.  What  are  the  principles 
which  we  must  now  put  into  practice?  For  purposes  of  tabula- 
tion and  description,  they  may  be  spoken  of  as  ''physiological" 
and  "antiseptic,"  though  the  difference  between  the  two  may  not 
be  so  sharp  as  such  a  precise  and  limited  statement  might  appear 
to  indicate. 

Physiological  Methods. — These  owe  their  origin  to  Sir  Almroth 
Wright.  The  problem  Wright  set  himself  to  solve,  in  the  case 
of  the  septic   "lymph  bound"  wound,    was    that    of    rendering 


90  ABSTRACTS  OF  WAR  SURGERY 

available,  once  more,  all  the  natural  defensive  mechanisms  pos- 
sessed by  the  body  fluids  and  tissues,  and  of  exalting  their  power 
by  bringing  them  into  play  in  far  larger  quantities  than  are 
usually  at  our  command  and  in  a  condition  which,  as  a  result 
of  vaccine  injections,  or  because  of  the  increased  antitryptic 
power  of  the  blood  serum  of  a  wounded  man,  finds  them  greatly 
augmented.  "We  have,  he  says,  to  promote  the  destruction  of  the 
microbes  which  have  been  carried  into  the  deeper  tissues;  we 
have  to  resolve  the  infiltration  in  the  walls  of  the  wound,  and  to 
get  rid  of  infected  sloughs ;  we  have  to  prevent  the  ' '  corruption 
of  the  discharges, ' '  and  to  inhibit  microbic  growth  in  the  wound ; 
we  have  to  be  constantly  on  our  guard  in  order  to  prevent  these 
active  and  passive  movements  which  propel  bacteria  along  the 
lymphatics,  and  which  carry  poisonous  bacterial  products  into 
the  blood ;  and  finally,  all  this  being  done,  we  have  to  get  rid  of 
the  surface  infection,  promote  the  processes  of  repair  in  the  wound, 
and  bring  together  the  wound  surfaces  so  that  they  may  heal. 

How  are  these  various  tasks  successfully  accomplished?  The 
blood  serum,  as  Wright  has  shown,  possesses  certain  remarkable 
properties.  Mechanically  it  is  the  agent  by  which  phagocytes 
are  washed  on  a  rising  tide  into  the  wound,  and  chemically  it 
has  a  powerful  bactericidal  efficiency  against  all  microorganisms, 
but  the  "serophytes,"  streptococci,  and  staphylococci  (the 
anaerobic  organisms  that  is  to  say)  are  destroyed  by  it.  The 
phagocytes,  as  Metchnikoff  long  ago  showed  us,  can  devour  and 
digest  microorganisms  of  all  kinds,  but,  tried  beyond  a  certain 
point,  they  perish  in  the  fight,  and  liberate  at  their  death  a 
ferment,  trypsin,  which  digests  the  native  albumens  in  the  serum, 
converts  them  into  peptone,  and  therefore  adds  enormously  to 
the  cultural  value  of  the  wound  discharges.  The  blood,  how- 
ever, is  normally  antitryptic,  and  this  quality  appears  in  cases 
of  infection  to  be  increased — there  is  an  antidote,  that  is  to  say, 
to  the  local  defect  of  the  phagocytes  and  the  consequence  at- 
taching thereto.  The  coagulability  of  the  serum  is  also  increased 
with  the  result  that  a  "rolling"  of  fibrin  forms  on  the  walls  of 
the  wounds,  and  prevents  the  access  to  the  wound  of  reinforce- 
ment of  serum  and  of  cells.  Wright's  method  consists  in  the 
application  of  a  "hypertonic"  solution  of  salt,  5  per  cent  or 
anything  over  that,  together  with  one-half  per  cent  citrate  of 
soda  (this  is  not  necessary).  The  principle  of  the  hypertonic 
method  is  to  make  use  of  the  bactericidal  power  of  fresh  serum 


ABSTRACTS  OF  WAR  SURGERY  91 

which  is  encouraged  to  flow  from  the  wound  surfaces  by  the 
application  to  them  of  a  more  concentrated  saline  solution  than 
blood  serum.    A  process  of  osmosis  is  at  work. 

The  action  of  hypertonic  saline  solutions  is  complex,  and  its 
virtues  conflicting.  It  attracts  water  from  the  blood  together 
with  all  the  protein  substances  contained  therein;  it  inhibits 
leucocytic  migration,  prevents  phagocytosis,  disintegrates  those 
leucocytes  with  which  it  is  brought  into  direct  contact  and  thus 
sets  free  a  tryptic  ferment  which  digests  the  albumens  of  the 
blood  serum.  It  delays  or  prevents  the  action  of  this  very  fer- 
ment which  it  has  caused  to  be  liberated.  It  inhibits  coagulation 
and  so  prevents  the  sealing  up  of  the  channels  through  which 
lymph  pours  into  the  wound.  It  appears  definitely  to  inhibit 
bacterial  activity  and  propagation. 

Antiseptic  Methods. — Among  these,  pride  of  place  will  cheerfully 
and  gratefully  be  conceded  to  the  Carrel-Dakin  procedure.  It 
consists  of  a  free  mechanical  exposure  and  cleansing  of  the  whole 
wound.  This  is  so  easy  to  say,  and  alas,  so  difficult  in  all  cases 
to  carry  out  adequately.  The  wound  so  made  is  then  lightly 
packed  with  gauze  into  which  a  number  of  Carrel's  tubes  are 
laid;  through  these  tubes  at  intervals  of  about  two  hours  Dakin's 
fluid  is  instilled.  Probably  full  realization  of  the  need  for  careful 
preparation  and  testing  of  Dakin's  fluid  is  not  universal;  nor 
of  the  rapid  deterioration  in  its  potency  if  it  is  allowed  to  be 
heated,  or  exposed  to  the  air,  or  stored  in  transparent  glass  bot- 
tles in  warm  places.  The  method  allows  of  the  early  secondary 
closure  of  wounds,  at  an  average  period  of  8  to  12  days;  and 
coming  when  it  did,  before  the  end  of  the  first  year  of  the  war, 
it  is  no  exaggeration  to  describe  its  effects  upon  the  treatment 
of  wounds  as  revolutionary. 

In  what  way  does  the  Carrel-Dakin  method  act?  Are  its  ef- 
fects produced  by  reason  of  the  strongly  antiseptic  properties  of 
Dakin's  fluid,  or  because  of  other  properties  not  directly  con- 
cerned with  the  killing  of  microorganisms?  Or  is  the  most 
excellent  technic  for  which  we  can  not  be  too  grateful  to  Carrel 
chiefly  responsible  in  that  it  necessitates  a  greater  general  care 
of  the  wound,  a  free  opening  of  all  recesses,  and  that  constant 
supervision  which  detects  at  the  earliest  moment  any  harmful 
development  on  the  granulating  surface?  If  strict  dependence 
is  placed  upon  the  microbial  curve,  it  would  appear  that  the 
author  of  the  method  believes  that  progressive  sterilization  of 


92  ABSTRACTS  OF  WAR  SURGERY 

the  wound  is  produced  by  the  chemical  action  of  Dakin's  fluid 
upon  the  bacterial  flora.  The  reduction  in  the  number  of  organ- 
isms even  irrespective  of  their  nature,  is  held  to  be  the  index  of 
the  germicidal  effect  of  the  fluid  applied.  Even  when  compara- 
tively small  quantities  of  a  potent  bactericidal  fluid,  like  that 
discovered  by  Dakin,  are  instilled  frequently  into  wound  cavities 
covered  by  sloughs  or  granulations,  the  killing  of  microbes  can 
hardly  be  a  serious  consequence.  For  these  organisms  can  prop- 
agate themselves  at  a  rate  with  which  the  most  powerful  germi- 
cide could  hardly  "catch  up,"  however  frequently  or  adequately 
supplied.  I  can  easily  conceive  of  an  "antiseptic,"  using  the 
word  in  its  clinical  sense,  which  is  not  in  the  smallest  degree 
"germicidal."  I  can  understand,  that  is  to  say,  that  a  wound, 
however  gravely  infected,  may  by  the  application  of  some  chem- 
ical substance  be  deprived  of  its  bacterial  flora,  in  very  great 
measure,  or  even  completely,  though  no  single  microorganism 
is  killed  by  this  substance.  An  "antiseptic,"  if  not  germicidal 
(that  is,  not  acting  chemically  upon  the  substance  of  which 
bacteria  are  composed),  might  yet  render  the  wound  sterile  either 
by  destroying  the  pabulum  of  the  bacteria,  so  that  they  are 
unable  to  flourish  and  to  propagate,  or  by  exalting  those  normal 
powers  of  resistance  possessed  by  body  tissues  apd  fluids,  or  by 
holding  up  the  bacteria  until  those  powers,  without  increase,  are 
capable  of  destroying  or  dispelling  the  infective  agents.  Or  does 
the  action  of  chemical  agents  on  the  leucocytes  so  alter  their 
metabolism  as  to  produce  substances  which  cause  degenerative 
processes  in  the  bacteria?  That  is,  are  involution  forms  of  bac- 
teria developed  by  the  relationship  of  these  agents  to  them? 
The  most  striking  effect  visible  to  the  eye  in  a  wound  treated 
by  the  Carrel-Dakin  method  is  that  the  surfaces  are  cleaned 
very  rapidly.  Dead  tissue,  even  large  sloughs,  are  quickly  di- 
gested away,  and  the  surface  becomes  smooth,  clean  and  bright 
red  in  color.  In  a  wound  not  yet  clean  in  all  its  parts  a  very 
different  microbial  curve  can  be  drawn  if  smears  are  taken  from 
the  smooth  red  portion  of  the  surface  and  from  the  edge  of  a 
slough.  It  is  the  dead  tissue  in  the  wound  that  keeps  the 
septic  processes  going.  If  this  is  destroyed,  bacterial  profusion 
and  virulence  both  rapidly  diminish  until  the  wound  is  ' '  clinically 
sterile."  If,  therefore,  a  substance  could  be  found  which,  without 
having  a  directly  noxious  effect  upon  bacteria,  could  rid  the 
wound  of  all  dead  tissue  and  allow  the  natural  defensive  mech- 


ABSTRACTS  OF  WAR  SURGERY  93 

anism  to  have  a  free  chance,  it  is  probable  that  the  wounds  would 
heal  as  kindly  as  they  do  under  the  Carrel-Dakin  system. 

What  appears  to  be  a  fulfilment  of  this  supposition  has  been 
published  since  the  above  paragraph  was  written.  Donaldson 
and  Joyce  {Lancet,  London,  1917,  ii,  445)  describe  a  nonpathogenic 
sporebearing  anaerobe,  which  acts  apparently  in  virtue  of  its 
proteolytic  powers  only  on  devitalized  tissues,  and  possibly  on 
tox-albumens,  and  appears  to  possess  no  power  of  attacking 
healthy  tissues.  The  powers  of  this  organism  are  directed  toward 
the  removal  not  only  of  the  grossly  damaged  tissues,  but  it  suc- 
ceeds also  in  attacking  the  microscopically  damaged  structures. 
As  a  result,  the  body  forces  are  freed  from  the  constant  menace  of 
septic  poisoning  and  are  thus  allowed  to  commence  the  work  of 
repair.  It  is,  therefore,  an  arguable  proposition  that  Dakin's 
fluid  as  applied  by  the  Carrel  technic  does  not  act  as  a  germicide 
but  rather  as  a  proteolytic  agent,  as  an  agent  destroying  those 
parts  of  the  wound  on  which  alone,  or  chiefly,  organisms  can  find 
a  place  to  propagate.  It  is,  after  all,  therefore  the  mechanical 
cleaning  of  the  wound  which  is  of  the  greatest  importance,  and 
the  action  of  Dakin's  fluid  is  perhaps  very  much  the  same  as 
that  of  the  surgeon's  knife  in  those  cases  where  the  wound  is 
excised. 

The  Carrel-Dakin  method  always  stops  short  of  perfection  in 
asepsis.  The  wound  in  my  experience  is  never  rendered  "sterile" 
by  this  method.  Organisms  can  be  found  in  smears  and  developed 
in  culture,  however  long  the  treatment  is  continued  in  a  large 
wound,  a  fact  which  seems  to  me  of  great  significance  in  relation 
to  the  question  of  the  bactericidal  value  of  Dakin's  fluid.  For 
when  fluid  in  the  same  quantity  as  ever  is  applied,  and  but  few 
microorganisms  remain,  their  ultimate  annihilation  appears  to 
be  impossible.  Perfect  sterility,  however,  we  have  long  known 
is  not  necessary  for  a  healing  by  first  intention,  though  the 
quality  of  that  healing  varies  decidedly  according  to  the  relative 
infectivity  of  the  wound.  The  fewer  and  less  harmful  the  organ- 
isms the  more  blameless  is  the  healing.  Surgeons  who  have 
worked,  as  surgeons  should  work,  with  a  bacteriologist  at  their 
elbows,  will  admit  they  have  frequently  closed  wounds  which 
were  proved  to  contain  microorganisms,  and  yet  have  obtained 
a  union  of  the  wound  that  was  good.  Until  I  adopted  my  present 
technic,  this  was  a  frequent  experience;  but  many  years  ago  I 
began  (I  was,  I  believe,  the  first  to  begin)  the  covering  of  the 


94  ABSTRACTS  OF  WAR  SURGERY 

skin  by  tetra  cloths  which,  overlapped  the  skin  edges,  and  since 
then  I  can  be  certain  that  in  all  clean  cases  the  wound  remains 
sterile  to  the  end  of  the  operation  and  a  flawless  healing  can  be 
confidently  expected.  Carrel  has  coined  the  phrase  "clinical 
sterilization"  to  indicate  that  condition  in  which  organisms  are 
•so  few  that  the  wound  can  safely  be  closed  and  good  healing 
obtained.  Regard  should,  however,  be  paid  not  only  to  the  num- 
ber of  the  microbes  but  to  their  nature.  I  do  not  like  to  find 
a  streptococcus  present  when  the  day  approaches  for  the  second- 
ary suture  of  a  wound.  Carrel's  method  must  rely  at  the  last 
upon  the  living  properties  of  the  tissues  to  destroy  or  render 
innocuous  the  organisms  still  remaining  in  the  wound  when  it  is 
closed.  It  is  true  that  they  are  few;  but  they  are  there  never- 
theless, and  must  be  overcome  if  the  wound  is  to  heal,  and  to 
remain  healed.  What  most  surgeons  have  learned  since  the 
introduction  of  this  technic  is  that  which  those  surgeons  who 
worked  with  a  bacteriologist  by  their  side  have  long  known; 
namely,  that  infected  wounds  (wounds  "clinically  sterile")  may 
heal  in  a  manner  to  which  the  term  "first  intention"  may  without 
injustice  be  applied. 

What  are  the  disadvantages  of  the  Carrel-Dakin  method?  I 
often  hear  it  said  that  it  is  a  difficult  method,  requiring  a  special 
training  of  the  surgeon,  that  it  requires  a  large  amount  of  glass 
and  rubber  tubing,  bottles,  etc. ;  that  it  is  costly  in  dressings,  and 
that  it  calls  for  constant  supervision  or  direction  by  the  surgeon. 
There  is  truthfully  no  great  validity  in  these  objections.  A  spe- 
cial instruction  of  the  surgeon  is  certainly  necessary  if  he  is 
to  observe  the  ritual  carefully,  and  to  understand  what  it  means ; 
but  so  it  may  be  said  is  a  special  training  necessary  for  the 
surgeon  when  any  new  technical  procedure  is  introduced.  The 
apparatus  is  cheap,  and  is  easily  obtained  and  lasts,  with  care 
for  months.  If  nurses  are  carefully  trained  to  do  the  dressings 
with  punctilious  care,  only  that  supervision  is  needed  from  the 
surgeon  which  he  should  give  to  every  case.  From  a  military 
point  of  view,  however,  it  is  a  difficult  method  of  practice,  for 
in  our  army  we  are  compelled  to  evacuate  a  large  proportion  of 
cases  to  England,  retaining  only  those  for  whom  movement  has 
proved  disastrous.  The  circumstances  under  which  Carrel  worked 
and  under  which  he  produced  his  splendid  results  could  not  con- 
ceivably be  made  applicable  to  a  whole  army.     Some  part  of 


ABSTRACTS  OF  WAR  SURGERY  95 

his  success  must  truthfully  be  given  to  his  opportunities  both  for 
receiving  the  cases  early  and  retaining  them  for  long  periods. 

The  chief  disadvantage  of  the  method  is  that  if  it  is  interrupted 
it  fails  lamentably.  When  cases  have  to  be  transferred  from 
France  to  England,  it  may  for  certain  reasons  be  impossible  to 
survey  all  the  cases  on  board  ship  or  on  the  train;  and  infection 
then  spreads  and  a  rancid  and  rampant  suppuration  is  present 
when  the  patient  arrives  at  a  base  hospital  in  England.  This  is, 
it  is  true,  an  objection  to  a  particular  application  of  the  method, 
rather  than  to  the  method  itself.  But  it  is  the  reason,  I  think, 
that  the  procedure  has  never  found  a  wide  or  general  acceptance 
in  the  British  Army,  though  it  has  many  warm  advocates,  and 
many  who  practice  it  with  a  success  equal  even  to  that  of  Carrel 
or  of  Chutro.  The  chief  successes  obtained  by  this  method  are  in 
the  early  cases,  in  those  in  which  treatment  can  begin  at  intervals 
of  not  more  than  six  or  seven  hours  after  the  wound  is  made. 
But  we  are  by  degrees  becoming  less  timorous  in  our  efforts  at 
primary  closure  in  precisely  this  group,  and  our  results  justify 
a  wider  acceptance  and  a  more  general  adoption  of  this  practice. 
In  later  cases  the  Carrel  method  is  beyond  question  a  therapeutic 
procedure  of  the  first  magnitude,  but  it  then  requires,  unwearying 
care  and  inexhaustible  patience  if  the  best  results  are  obtained. 

Rutherford  Morison's  Method. — This  method  is  widely  practiced 
in  the  base  hospitals  in  England,  and  by  many  surgeons  is  con- 
sidered the  most  satisfactory  of  all.  The  technic  is  as  follows : 
A  wound,  say  of  the  arm,  leading  down  to  a  compound  com- 
minuted fracture  of  the  humerus  is  freely  opened  up,  after  such 
preparation  of  the  arm  and  of  the  surrounding  parts  as  is  made 
in  all  cases  about  to  undergo  operation.  The  wound  may  be  en- 
larged in  any  direction  in  order  to  make  sure  that  no  recesses 
in  it  remain  undiscovered.  All  granulation  tissue  is  vigorously 
scraped  away  from  the  wound  surfaces ;  bleeding  points  are 
secured;  obviously  dead  and  loose  portions  of  bone,  or  pieces 
of  cloth,  or  projectiles  are  removed.  The  wound  is  packed  with 
dry  gauze  for  a  minute  or  two,  while  towels  about  the  wound 
are  changed  if  necessary,  and  while  the  surgeon  replaces  all 
instruments,  gloves,  etc.,  with  those  freshly  sterilized.  The  dry 
gauze  is  removed,  the  wound  sponged  everywhere  with  gauze 
moistened  with  methylated  spirit.  On  to  the  raw  wound  surface 
a  thin  layer  of  a  preparation  known  as  "Bipp"  (bismuth  subni- 
trate  or  carbonate,  one  part;  iodoform,  two  parts;  paraffin  in 


96  ABSTRACTS  OF  WAR  SURGERY 

quantity  sufficient  to  make  a  soft  paste)  is  applied.  With  a  gauze 
swab  this  paste  is  rubbed  well  into  the  wound,  which  is  then 
sutured  from  end  to  end  without  drainage.  The  arm  is  fixed 
on  a  splint,  and  the  wound  left  untouched  for  10  days.  At  the 
end  of  this  period  it  is  usually  found  healed  or  nearly  so ;  another 
dressing  is  applied,  and  allowed  to  remain  10  days.  No  further 
dressing  is  needed.  The  absence  of  frequent  dressings  is  an  im- 
mense advantage  and  a  comfort  beyond  words  to  an  anxious, 
overwrought  patient. 

Why  does  Morison's  method  prove  so  successful?  Is  it  the 
free  mechanical  cleansing  of  the  wound  that  is  of  chief  import- 
ance, or  is  there  some  antiseptic  or  physiological  virtue  in  the 
"Bipp"  as  a  whole,  or  in  any  of  its  constituent  parts?  It  is 
almost  certain  that  in  the  perfect  mechanical  cleansing  of  the 
wound  lies  the  secret  of  the  method.  For  I  have  treated  wounds 
in  exactly  Morison's  method  and  have  omitted  the  paste,  and  have 
seen  the  wounds  heal  as  kindly  as  when  it  was  used.  If  there  is 
a  virtue  in  the  paste,  in  which  of  the  ingredients  does  it  lie? 
Probably  in  the  paraffin  which  produces  that  anaerobic  state  in 
which  healing  can  most  rapidly  take  place.  Morison,  at  my  sug- 
gestion, tried  his  methods  in  two  cases,  omitting  the  ''Bipp,"  and 
he  allows  me  to  say  that  they  healed  as  well  as  the  others  treated 
with  the  paste. 

Such  is  a  brief  statement  of  the  present  position  with  regard 
to  the  treatment  of  war  wounds.  It  must  never  be  forgotten  that 
the  time  element  is  always  an  important  factor  and  that  the 
problem  of  dealing  with  an  early  contaminated  wound  is  not 
identical  with,  indeed  may  be  marvelously  different  from  that 
concerned  with  a  late  infected  wound.  The  conditions  in  the 
early  hours,  when  the  patients  are  at  the  casualty  clearing  sta- 
tions in  France,  are  very  different  from  those  to  be  combated 
when  the  patient  reaches  a  base  hospital  in  England,  after  the 
lapse  of  many  days  or  many  weeks.  Finally,  in  the  English 
Army,  with  the  Channel  and  the  long  train  journey  interposed 
between  the  hospitals  in  France  and  those  at  home,  a  new  and 
very  difficult  set  of  circumstances  must  be  taken  into  account. 

But,  wherever  and  whenever  the  patient  is  seen,  the  most 
urgent  desire  and  the  paramount  concern  of  the  surgeon  is  to 
adopted,  whatever  procedure,  whether  of  physiological  or  of 
antiseptic  principle,  is  trusted,  it  is  the  suture  of  the  wound  at 
secure   closure   of   the   wound.     Whatever   mode   of   dressing   is 


ABSTRACTS  OF  WAR  SURGERY  97 

the  earliest  opportune  moment  that  must  be  the  goal  of  every 
effort.  So  far  as  our  present  knowledge  will  allow  us  to  formu- 
late conclusions,  the  following  deductions  may  usefully  be  drawn : 

Conclusions. — Perfect  mechanical  cleansing — that  is,  the  exci- 
sion of  all  contaminated,  infected,  or  dead  parts — the  removal  of 
all  fragments  of  clothing  (by  far  the  most  important  of  all  causes 
of  continuing  infection  in  a  wound)  and  of  all  projectiles,  is  the 
supreme  necessity  in  all  cases. 

In  early  cases  this  may  allow  of  immediate  closure  of  the 
wound,  which  will  be  followed  by  healing  in  the  great  majority 
of  cases,  say  in  80  per  cent  or  perhaps  even  90  per  cent  of  those 
in  which  there  is  no  loss  of  tissue. 

In  infected  early  cases  the  mechanical  exposure  and  cleansing 
may  be  followed  by  a  treatment  directed  to  the  removal  of  the 
remaining  infection.  Physiological  and  antiseptic  methods  have 
each  their  advocates.  The  aim  of  both  is  to  permit  of  the  earliest 
prudent  secondary  closure  of  the  wound.  In  infected  late  cases, 
a  thorough  mechanical  exposure  and  cleansing  of  the  wound 
and  the  parts  around  will  allow  of  secondary  closure  forthwith 
if  certain  antiseptic  pastes  are  used.  Experience  shows  that  sim- 
ilar results  have  followed  upon  this  mechanical  treatment  of  the 
wound  without  the  introduction  of  antiseptics.  A  further  trial 
in  this  class  of  cases  may  show  that  the  natural  defenses  of  the 
tissues  are  ample  to  deal  with  the  infections  then  remaining. 

It  is  the  natural  defensive  powers  of  the  body  fluids  and  tissues, 
of  serum  and  leucocytes,  that  are  the  chief  agents  in  finally 
subduing  the  bacterial  infection  in  a  wound.  Sufficient  reliance 
does  not  appear  to  be  placed  upon  the  stupendous  power  the 
body  tissues  possess  for  controlling  infection. 

Finally  full  emphasis  must  be  laid  on  the  paramount  necessity 
for  the  complete  immobility  of  wounded  parts  at  all  times  and 
on  all  occasions.  So  will  one  of  the  most  powerful  agencies 
making  for  reinfection  and  autoinoculation  be  kept  in  check. 

WOUND  EXCISION.— Rev.  of  War  Surg,  and  Med.,  May,  1918, 
i,  No.  3,  p.  21. 

At  the  February  meeting  of  the  Association  of  Military  Surgeons 
of  the  United  States  Army  in  France,  Prof.  A.  Depage  furnished 
an  account  of  the  principles  underlying  wound  excision  in  such 
clear  and  orderly  fashion  that  we  reprint  it,  with  only  insignificant 
deletions,  from  the  Journal  of  the  American  Medical  Association, 
March  23,  1918,  page  880 : 


98  ABSTRACTS  OF  WAR  SURGERY 

When  we  find  ourselves  in  the  presence  of  a  flesh  wound  from 
a  bullet,  with  punctiform  orifice,  we  consider  it  useless  in  most 
cases  to  incise,  the  opening  healing  as  a  rule  spontaneously  with- 
out showing  any  complications.  We  have,  however,  found  ex- 
ceptions in  wounds  from  a  gun  fired  point-blank  or  at  a  short 
distance,  such  wound  being  sometimes  in  pressing  need  of  inci- 
sions. In  fact,  in  these  cases  the  projectile  almost  always  causes 
a  tearing  of  tissues,  a  veritable  laceration,  with  an  area  of  attri- 
tion more  or  less  deep,  in  danger  of  mortification;  it  would  be 
imprudent  not  to  take  measures  of  relief.  We  relieve  by  in- 
cisions also  when  the  bullet  has  severed  an  important  artery 
and  when  an  aneurysmal  hematoma  has  manifested  itself.  Here, 
however,  the  greatest  precautions  and  the  avoidance  of  any  care- 
lessness are  necessary.  Cases  of  this  kind  are  among  the  most 
serious  and  should  be  undertaken  only  by  an  expert  surgeon,  very 
sure  of  himself.  When  a  large  artery  is  cut  and  the  nutrition 
of  the  member  is  in  danger  he  can  with  great  advantage  use 
Tuffier's  paraffined  tube. 

Large  severed  nerves  form  another  class  of  wounds  in  which 
we  incise  immediately.  We  can  not  insist  too  much  on  the 
examination  of  the  motor  and  sensory  functions  in  the  region 
of  the  nerve  supposed  to  be  injured.  The  course  to  follow  is 
summed  up  by  the  laying  bare  of  the  nerve,  the  suturing  of  the 
two  ends,  and  the  placing  of  the  sutured  nerve  in  the  neighbor- 
ing muscular  tissue. 

Fractures  caused  by  bullets  require  in  general  an  incision. 
The  operation  necessary  depends  more  on  the  complications  just 
cited  than  on  the  fracture  itself. 

In  wounds  from  artillery  projectiles  the  conditions  are  not  the 
same;  wounds  from  bursting  shells  or  bombs  are  much  more 
serious  and  are  practically  always  infected,  and  for  this  reason 
require  more  treatment.  Only  the  small  splinters  the  size  of  a 
grain  of  wheat  are  left  in  the  flesh,  especially  if  there  are  a 
great  many  of  them.  All  the  projectiles  of  more  important 
dimensions  are  extracted,  and  the  wound  is  treated  according 
to  the  superficiality  or  depth  of  the  lesion. 

Subcutaneous  through-and-through  wounds,  suppurating  com- 
paratively little,  do  not  imperatively  require  incision.  However, 
it  is  better  to  have  recourse  to  it,  because  of  the  frequent  pres- 
ence of  shreds  of  clothing  in  the  wound.  If  circumstances  per- 
mit, we  extract  the  foreign  matter  en  masse  through  the  healthy 
tissue,  and  we  make  the  suture  at  once. 


ABSTRACTS   OF    \\  \i;   SURGER7  '■'> 

If  the  wound  is  slight  with  subcutaneous  course,  the  extrac- 
tion of  the  projectile  is  in  order.  However,  if  the  course  is  no 
more  than  2  or  3  cm.,  we  do  not  incise.  We  extract  the  foreign 
body  with  the  shreds  of  clothing  by  means  of  a  simple  curette. 
If  the  course  is  longer,  we  treat  it  as  a  through-and-through 
wound. 

In  deep  through-and-through  penetrating  wounds  with  the  pro- 
jectile included,  the  question  is  no  longer  debatable ;  incision  is 
necessary  in  every  case. 

Object  of  Treatment. — An  incision,  by  opening  wide  the  injured 
area,  relieves  the  compression  of  the  tissues,  constricted  by  the 
aponeurotic  coverings,  and  helps  the  secretions.  There  must  be 
eliminated  from  the  wound  not  only  the  infected  foreign  bodies 
(splinters,  shreds  of  clothing,  etc.),  but  also  the  contaminated 
tissues,  such  as  injured  or  mortified  flesh,  favoring  the  spread  of 
germs.  Let  us  notice  in  this  respect  that  the  area  of  attrition, 
of  cellular  compromise,  is  not  limited  to  the  tissues  that  have  been 
directly  in  contact  with  the  projectile,  but  extends  to  a  depth 
of  0.5  to  1  cm.,  sometimes  even  to  2  cm.  The  vitality  of  these 
tissues  is  affected,  and  there  is  a  great  advantage  in  not  allowing 
them  to  remain  for  any  length  of  time  with  elements  less  af- 
fected or  completely  unaffected.  Subsequent  progress  of  the 
wound  in  its  rapid  cure  depend  on  the  promptness  of  the  first 
treatment  and  the  care  in  its  administration. 

Technic  of  Excision  of  Dead  Tissue. — Certain  surgeons  have 
recommended  the  removal  of  the  traumatic  matter  en  masse  as 
one  would  take  out  a  tumor.  The  length,  depth,  and  direction 
of  the  wound  being  exactly  ascertained  at  need  by  the  introduc- 
tion of  a  metal  conductor,  and  the  wound  being  completely 
isolated  from  the  field  of  operation,  they  circumscribe  the  open- 
ing with  an  oval  incision,  of  which  the  large  axis  corresponds  to 
the  direction  of  the  wound.  They  cut  successively  the  skin,  cel- 
lular tissues,  the  aponeurosis,  and  the  muscles,  constantly  keep- 
ing in  healthy  tissue,  in  such  a  way  as  to  limit  the  area  that  sur- 
rounds the  entire  wound.  Then  they  remove  en  masse  the  in- 
jured tissue,  being  careful  to  keep  the  healthy  from  the  con- 
taminated.    The  suture  may  follow  immediately. 

Such  a  complete  operation  would  constitute  without  doubt  an 
ideal  method  of  treatment,  if  the  traumatic  sources  were  definitely 
limited  and  if  we  could  cut  into  the  flesh  without  considering 
the  organs  it  surrounds.  But  it  is  needless  to  say  that  these  con- 
ditions do  not  exist  when  it  is  a  question  of  deep  and  extended 
lesions.    It  is  better  then  to  reserve  this  process  solely  for  super- 


100  ABSTRACTS  OF  WAR  SURGERY 

ficial  and  short  wounds  of  which  it  was  a  question  before.  The 
only  incision  truly  rational  consists  in  a  wide  opening  of  the 
seat  of  the  wound,  such  as  is  practiced  by  the  great  majority  of 
surgeons.  Two  things  are  necessary,  the  incision  and  the  ex- 
cision of  tissues. 

Before  proceeding  to  the  excision  of  dead  tissue,  the  surgeon 
must  find  out,  as  accurately  as  possible,  the  shape  of  the  wound 
by  different  anatomic  methods.  They  are  indicated  in  the  follow- 
ing manner:  (1)  For  through-and- through  wounds,  orifices  of 
entrance  and  exit.  (2)  For  the  lesser  wounds,  the  orifice  of  en- 
trance, on  the  one  hand,  and  the  situation  of  the  projectile  as 
determined  by  the  roentgen  ray,  the  fluoroscope,  or  the  electric 
vibrator,  on  the  other. 

The  form  of  the  channel  being  determined,  the  incision  must 
be  made  so  as  to  permit  a  perfect  access  to  the  wound  without 
any  further  damage  anatomically.  According  to  our  experience, 
the  direction  of  the  incisions  must  vary  according  to  the  part 
wounded  and  the  nature  of  the  wound: 

(a)  In  wounds  of  the  arm,  forearm,  and  lower  third  of  the  leg, 
transverse  incisions  are  inadmissible  because  of  the  danger  of  cut- 
ting important  organs,  longitudinal  incisions  alone  are  allowed. 
Whether  it  is  a  question  of  the  lesion  of  a  single  aspect,  or  whether 
both  the  anterior  and  posterior  aspects  have  been  simultaneously 
affected,  these  incisions  will  always  be  sufficient  to  permit  of 
complete  excision  of  dead  tissue.  The  anterior  aspect  of  the  leg 
requires  likewise  a  longitudinal  incision,  with  this  restriction, 
however,  that  in  its  upper  third  a  wound  of  the  anterior  tibial 
artery  may  demand  a  transverse  cutting  of  the  muscle. 

(&)  Wounds  of  the  thigh  (anterior  and  posterior  surface),  the 
popliteal  space  and  the  calf,  through-and-through  wounds,  and 
simple  penetrating  wounds,  involving  both  aspects,  must,  in  gen- 
eral, be  treated  by  incisions  parallel  to  the  axis  of  the  member. 
A  transverse  incision  would  not  in  this  case  offer  any  advantage, 
and  would  be  of  such  a  nature  as  to  occasion  very  serious  dam- 
age. Two  longitudinal  incisions,  one  in  the  anterior  and  the  other 
in  the  posterior  surface,  will  always  permit  of  a  wide  approach 
to  the  seat  of  the  wound. 

In  the  case  of  a  seton  or  deep  penetrating  wound,  taking  in 
only  one  aspect,  longitudinal  incisions  would  no  longer  suffice. 
The  muscular  masses  are  too  thick  to  give  access  to  the  deep  parts 
of  the  wound.  It  is  important,  however,  that  the  latter  should 
be  deeply  incised  in  order  to  avoid  accidents  of  gas  infection, 
especially  to  be  feared  in  great  muscular  masses.     Under  these 


ABSTRACTS    OF    WAR    SURGERY  101 

conditions  one  will  often  be  led  to  make  a  tranverse  incision,  cut- 
ting all  the  organs  or  a  part  of  the  organs  interposed  between  the 
cutaneous  surface  and  the  deep  wound ;  on  the  anterior  surface 
of  the  thigh  the  anterior  muscle  is  incised,  also  the  vastus  ex- 
ternus,  and  perhaps  the  tendons  of  the  fascia  lata ;  on  the  pos- 
terior face,  the  biceps  and  the  semimembranosus  on  the  thick  of 
the  calf,  the  twin  muscles;  and  on  the  posterior  surface  of  the 
arm  the  triceps.  It  goes  without  saying  that  the  transverse  in- 
cisions must  concern  only  the  muscles  and  the  aponeurosis,  and 
respect  the  nerves  and  the  vessels. 

After  the  excision  of  dead  tissue  it  is  well  when  possible  to 
reestablish  the  continuity  of  the  severed  muscles,  with  catgut 
stitches  in  U  form,  with  the  object  of  reuniting  the  two  ends, 
suturing  at  least  partially  the  aponeurosis  and  the  skin.  The 
transverse  incision  thus  made  leaves  no  functional  trace,  on  con- 
dition, of  course,  that  the  suture  holds. 

If  there  is  any  doubt  on  the  subject  of  the  cleanliness  of  the 
deep  wound,  the  suturing  of  severed  muscles  may  be  postponed 
two  or  three  days.  By  this  time  the  surgeon  will  be  sure  of  the 
nature  and  degree  of  the  possible  infection. 

Under  certain  circumstances,  when  the  excision  is  done  late, 
and  there  is  already  a  deep  infection,  immediate  suture  of  the 
muscular  ends  must  be  given  up. 

If  it  is  a  question  of  superficial  through-and-through  wound, 
the  free  edges  of  the  two  orifices  are  resected  and  then  united  by 
cutting  the  intervening  bridge  of  tissues,  so  as  to  transform  the 
course  of  the  wound  into  a  groove.  Then,  with  a  pair  of  heavy 
scissors,  the  injured  tissues  are  completely  removed  from  the  sur- 
face of  the  groove. 

To  follow  then  the  course  of  the  wound  in  its  depth,  precau- 
tions must  be  taken  against  introducing  a  conductor,  such  as  a 
grooved  probe,  which  might  easily  be  lost  in  the  muscular  tissues. 
The  best  way  to  reach  the  depth  of  the  wound  is  to  lift  the  edges 
of  the  muscles  with  two  forceps,  following  the  direction  of  the 
wound,  and  to  resect  the  injured  parts.  If  at  any  time  one  loses 
the  direction,  which  happens  often  in  the  deeper  parts  of  the 
wound,  a  gloved  finger  introduced  into  the  opening  will  find  it 
again  without  difficulty.  It  is  important  to  notice  that  the  cut 
muscles  contract,  and  in  the  course  of  the  work  of  cleaning 
the  ends  must  be  looked  for  in  order  to  excise  the  injured  parts. 

The  injured  muscles  must  be  resected  on  all  the  surface  of  the 
wound  up  to  the  healthy  tissue.     This  is  recognized  by  its  con- 


102  ABSTRACTS    OF   WAR   SURGERY 

tractibility  and  by  its  redness,  which  contrasts  with  the  dull  color 
of  the  bruised  flesh. 

The  incision  in  the  course  of  its  progress  leads  to  the  foreign 
body,  which  is  extracted  with  the  shreds  of  clothing.  When  the 
surface  is  largely  exposed  it  is  well  to  irrigate  the  wound  with 
neutral  solution  of  chlorinated  soda  or  with  warm  physiologic 
sodium  chlorid  solution,  which  shows  up  the  bruised  and  wounded 
parts. 

Regarding  the  proper  disposition  of  bone  fragments,  some  find 
it  better  to  remove  all  splinters  by  the  subperiosteal  method; 
others  cling  to  the  idea  that  only  those  splinters  that  are  free 
should  be  removed,  but  my  idea  in  this  respect  is  that  if  the  wound 
is  such  that  immediate  suture  may  be  attempted  I  take  out  the 
fragments.  If,  on  the  contrary,  it  is  evident  that  the  suture  can 
not  be  made,  by  reason  of  the  extent  of  damage,  I  do  not  remove 
any  splinters  in  the  course  of  the  operation,  considering  it  prefer- 
able to  let  those  splinters  affected  by  necrosis  eliminate  them- 
selves spontaneously  as  fast  as  the  growth  progresses.  This 
process  has  the  great  advantage  of  not  being  followed  by  a  psen- 
darthrosis  and  of  shortening  noticeably  the  first  operation,  a 
thing  to  be  taken  into  account  when  it  is  a  question  of  a  serious 
fracture,  and  the  patient  is  in  a  state  of  shock. 

Suture  of  Wounds. — When  we  incise  a  wound  to  prevent  in- 
fection we  must  at  the  same  time  try  to  put  it  in  a  state  most 
favorable  to  a  suture. 

This  may  be  done  immediately  after  the  excision  of  dead  tissue 
(immediate  suture),  or  within  the  first  five  or  six  days  (delayed 
primary  suture),  in  which  case  it  is  executed,  as  in  the  immediate 
suture,  by  the  simple  approximation  of  the  edges,  or  finally,  the 
suture  may  be  made  after  sterilizing  the  wound  with  neutral 
solution  of  chlorinated  soda  (secondary  suture).  The  latter  is 
done  the  eighth  day,  after  the  wound  is  covered  with  granula- 
tions. This  necessitates  always  the  freshening  of  the  edges,  and 
it  is  that  which  distinguishes  it  from  the  preceding  sutures. 

In  immediate  suture,  the  treatment  varies  according  to  the  seat 
of  the  lesion:  (a)  For  articular  wounds,  immediate  suture  is  in 
order,  unless  the  bony  lesions  are  too  extensive.  (6)  For  wounds 
on  the  head,  face,  feet,  or  hands  the  richness  of  venous  blood  and 
lymphatic  fluid  allows  the  surgeon  to  make  the  immediate  suture 
in  perfectly  systematic  fashion,  (c)  For  flesh  wounds  and  frac- 
tures, indications  for  the  immediate  suture  are  very  relative,  but 
surgeons  are  inclined  more  and  more  to  generalize  them.  The 
suture  must  be  made  within  12  hours  after  the  wound  has  been 


ABSTRACTS  OF  WAR  SURGERY  L03 

inflicted  and  only  when  the  surgeon  can  watch  it  during  at  least 
15  days.  It  offers,  as  special  advantage,  automatic  reparation  of 
the  torn  tissues,  but  the  infections  that  it  occasions  are  always 
rapid  and  serious  diffuse  phlegmonous  infections  or  gas  gangrene. 

Delayed  primary  suture  is  especially  adapted  to  flesh  wounds 
and  open  fractures.  It  is  done  after  bacteriologic  tests,  made  in 
the  following  way:  (a)  At  the  first  dressing  (from  12  to  24  hours 
after  excision  of  dead  tissue)  we  make  a  culture  test  by  direct 
examination.  •(&)  At  the  second  dressing  (from  36  to  48  hours 
after  excision  of  dead  tissue)  we  take  a  new  culture.  If  the  first, 
culture  does  not  show  the  presence  of  streptococci,  and  if  the 
microbic  enumeration  does  not  go  beyond  one  microbe  to  two 
fields,  we  make  a  suture.  We  never  suture  if  the  enumeration  at 
the  second  dressing  shows  a  rising  in  the  microbic  curve,  even 
if  the  microbes  are  not  streptococcic.  The  delayed  primary  suture 
rarely  results  in  failure,  involving  serious  accidents.  It  offers  the 
inconvenience  of  requiring  two  operations ;  but  the  second  is  of 
minor  importance. 

Secondary  suture  is  reserved  for  wounds  nonsuturable  during 
the  first  days  because  of  too  much  torn  tissue  or  some  threatened 
infection.  It  offers  the  great  advantage  of  giving  perfect  security, 
but  it  retards  the  cure  and  never  gives  so  complete  an  anatomic 
restitution  as  the  preceding  sutures.  We  use  it  regularly  when 
the  microbic  curve  keeps  below  one  microbe  to  four  fields  in  two 
successive  examinations,  and  the  culture  discloses  no  streptococci. 
The  deplorable  results  obtained  in  those  cases  have  allowed  us  to 
establish  fairly  exact  rules  on  the  treatment  of  wounds,  for  and 
against,  by  suturing. 

WOUND  INFECTIONS:  SOME  NEW  METHODS  FOR  THE 
STUDY  OF  THE  VARIOUS  FACTORS  WHICH  COME 
INTO  CONSIDERATION  IN  THEIR  TREATMENT.— A.  E. 

Wright,  Proc.  Roy.  Med.  and  Chir.  Soc,  London,  1915,  viii, 
p.  41. 

In  the  present  war  the  fact  which  is  of  astonishing  importance 
is  that  always  every  wound  is  infected,  some  of  them  very  badly 
so.  The  clothing  and  skin  of  the  soldiers  are  usually  in  a  filthy 
condition.  The  projectile  passing  through  this  zone  of  filth  neces- 
sarily carries  infection  along  its  path,  many  times  very  deep  and 
beyond  the  reach  of  antiseptics.  This  results  in  a  primary  in- 
fection of  streptococcus  with  organisms  from  the  feces,  especially 
the  gas  bacillus  and  tetanus  bacillus.     Death  may  result  from 


104  ABSTRACTS  OF  WAR  SURGERY 

erysipelas,  cellulitis,  tetanus,  or  gas  gangrene.  If  the  wound 
becomes  open,  and  aerobic  conditions  prevail,  a  secondary  in- 
fection with  other  pus  organisms — especially  bacillus  proteus — 
may  result. 

The  author  has  undertaken  a  series  of  experiments  in  connec- 
tion with  wound  infections.  The  first  problem  attacked  was: 
Can  the  microbes  which  are  found  in  wound  infections  live  and 
multiply  in  the  unaltered  blood  fluids?  By  means  of  capillary 
pipettes  successive  dilutions  of  pus  were  made,  1  to  10,  1  to  100 
to  1  to  100,000.  These  were  then  separately  mixed  with  an  equal 
quantity  of  normal  serum.  After  incubation  it  was  found  that : 
(1)  higher  dilutions  of  pus  gave  only  streptococcus;  (2)  lower 
dilutions  gave  streptococcus,  staphylococcus,  and  an  anaerobic 
bacillus;  (3)  all  other  organisms  were  inhibited  or  appeared  only 
after  fairly  heavy  sowing  with  pus  and  comparatively  late. 

Pyogenic  organisms  are  therefore  classified  into  (1)  serophytes 
— those  finding  foodstuffs  ready  made  in  blood  fluids  and  can,  in 
the  absence  of  phagocytes,  grow  without  restraint;  and  (2)  sero- 
saprophytes — those  which  can  not  grow  and  multiply  in  the  blood 
fluids  until  a  change,  probably  a  degenerative  change,  has  passed 
over  those  fluids. 

The  next  problem  was  to  determine  whether  the  lymph  in  a 
wound  acted  similarly  to  the  normal  blood  serum.  By  means  of 
a  special  glass  leech  it  was  possible  to  collect  the  lymph  from  the 
wall  of  a  wound  and  obtain  it  practically  free  from  phagocytes. 
It  was  found  that,  whereas  the  wound  itself  was  teeming  with 
many  varieties  of  pus  organisms,  both  serophytes  and  serosapro- 
phytes,  the  lymph  within  the  leech  showed  a  pure  culture  of 
streptococcus. 

The  problem  next  arose  as  to  what  was  the  cause  of  this  "cor- 
ruption of  the  lymph"  in  the  wound  which  allowed  all  forms  of 
organisms  to  grow.  It  has  been  shown  that  serosaprophytes  re- 
quire a  change  in  serum  before  it  can  be  utilized  by  them  as 
food.  This  change  is  opposed  to  the  antitryptic  property  of  the 
serum.  It  is  only  when  this  antitryptic  property  has  been  over- 
whelmed by  an  excess  of  trypsin  that  the  proper  preparation  of 
the  serum  for  the  serosaprophytes  can  result.  In  a  wound  the 
antitryptic  power  of  the  serum  may  be  overwhelmed  by  the 
trypsin  obtained  either  from  an  especially  large  number  of  bac- 
teria or  by  the  trypsin  liberated  from  broken  down  phagocytes. 
This  "passive  defense"  of  the  blood  afforded  by  its  antitryptic 
power  prevents  microbes  from  converting  to  their  uses  the  nutri- 
ent substances  of  the  blood  fluids  and  must  greatly  assist  the 


ABSTRACTS  OF  WAR  SURGERY  105 

"active  defense"  afforded  by  the  phagocytes  and  the  bacterio- 
tropic  substances  in  the  blood. 

The  next  problem  attacked  was :  What  are  the  factors  which 
influence  the  emigration  of  white  blood  corpuscles  into  the  wound. 
The  method  used  was  as  follows :  Capillary  tubes  were  filled  with 
blood  and  the  chemotactic  substance  under  question  and  immedi- 
ately centrifuged.  On  clotting  the  cellular  elements  were  at 
the  bottom  of  the  tube  and,  after  incubation,  it  was  possible  to 
determine  how  far  the  phagocytes  had  emigrated  into  the  clear 
clot  above. 

By  this  method,  the  following  data  were  determined:  (1) 
Leucocytes  will  move  in  any  direction  toward  a  chemotactic  sub- 
stance. (2)  Anaerobic  conditions  are  more  favorable  for  emigra- 
tion than  aerobic.  (3)  Emigration  occurs  more  freely  at  40°  than 
at  37° ;  does  not  occur  at  15° ;  when  exposed  to  a  temperature 
of  0°  for  one  hour  and  when  the  temperature  is  raised  emigration 
takes  place  as  before.  (4)  Vapor  of  ether  does  not  affect  emigra- 
tion. Vapor  of  chloroform  abolishes  it.  (5)  Physiological  salt 
solution  causes  vigorous  emigration  of  white  cells.  Strong  salt, 
e.  g.,  5  per  cent  solution — suppresses  emigration.  (6)  Bacterial 
suspensions  when  concentrated  suppress  emigration ;  weaker  dilu- 
tions cause  vigorous  emigration;  very  weak  dilutions  act  only  as 
diluent  acts. 

The  end-result  in  these  tubes  with  blood  and  bacteria  may  be : 
(1)  either  destruction  of  the  bacteria  or  (2)  an  overrunning  by  the 
bacteria  with  the  breaking  up  of  the  clot  due  to  the  liberation  of 
trypsin  from  broken  down  phagocytes. 

In  the  treatment  of  wound  infections  the  first  method  which 
suggests  itself  is  the  antiseptic  method.  Antiseptics  are  of  great 
use  as  a  preliminary  application  before  operation  and  in  recent 
superficially  infected  wounds,  e.  g.,  a  compound  fracture.  In 
wounds  in  war,  however,  the  conditions  are  different.  When  the 
wound  reaches  the  surgeon  it  is  already  infected  deeply  beyond 
the  reach  of  antiseptics.  The  track  of  the  projectile  is  blocked 
by  blood-clot  and  hernia  of  muscle.  The  best  that  could  be  ob- 
tained in  these  infections  would  be  only  a  partial  sterilization  and 
the  infection  would  in  a  few  days  be  as  bad  as  before.  Concen- 
trations of  the  antiseptic  which  would  be  effective  on  the  skin 
would  be  ineffective  in  a  wound,  because  its  action  would  be 
neutralized  by  the  body  fluids  and  pus. 

Is  there  any  reasonable  prospect  of  sterilizing  the  wound  by 
the  application  of  antiseptics?  It  is  possible  to  sterilize  the  pus 
in  the  cavity  of  the  wound.    There  are,  however,  recesses  which 


106  ABSTRACTS  OP  WAR  SURGERY 

can  not  be  reached  and  the  granulation  tissue  in  the  walls  of  the 
wound  hold  microbes  which  it  would  be  impossible  to  sterilize. 
Since  it  is  impossible  to  sterilize  a  wound  what  is  the  advantage 
to  the  patient  of  having  the  number  of  microbes  reduced  ?  "Wright 
does  not  believe  there  is  any  advantage  since  the  reduction  is 
merely  temporary.  The  soil  may  be  even  made  more  favorable 
for  the  microbes  by  the  use  of  antiseptics.  Apparently  the  only 
use  of  antiseptics  in  the  treatment  of  wounds  is  as  a  prophylactic 
of  the  graver  infections  which  were  present  before  Lister's  time. 
As  treatment  the  method  is  not  effective. 

The  next  method  discussed  is  called  the  physiological  method. 
This  method  is  the  basis  of  the  surgical  methods  usually  advo- 
cated :  namely,  the  opening  and  draining  of  abscesses ;  free  in- 
cisions into  infiltrated  tissues ;  hot  fomentations ;  leaving  opera- 
tion wounds  unsutured ;  and  dispensing  with  flaps.  These  meth- 
ods cause  an  outflow  of  pus  with  the  influx  of  fresh  lymph  and 
phagocytes.  It  is  of  advantage  in  most  wounds  to  have  a  marked 
outgoing  current  of  lymph  with  sufficient  phagocytes  with  it  to 
antagonize  microbes  present  but  not  to  destroy  the  antitryptic 
power  of  the  serum.  In  wounds  where  the  infection  is  in  dry 
and  infiltrated  tissues  with  a  small  amount  of  serum  exuding,  it 
may  seem  undesirable  to  have  emigration  of  many  phagocytes, 
also  their  destruction  in  the  absence  of  fresh  lymph  may  result 
in  the  overpowering  of  the  antitryptic  substance  in  the  serum. 
This  would  result  in  a  favorable  medium  for  serosaprophytes. 

The  lymphagogue  which  the  author  has  used  successfully  for 
many  years  consists  of  a  solution  of  sodium  chloride  5  per  cent, 
sodium  citrate  0.5  per  cent. 

The  third  method  of  treatment  is  vaccine  therapy.  In  civil 
life  vaccines  have  proved  eminently  successful  in  prophylaxis  of 
certain  diseases  and  in  the  treatment  of  certain  local  infections. 
In  war,  experiments  have  not  been  carried  out  to  an  extent  to 
warrant  conclusions.  In  cases  of  erysipelas  and  cellulitis  the 
results  are  often  brilliant.  In  well-drained  wounds  vaccines 
seem  to  favor  phagocytosis  and  increase  the  outpouring  of  lymph. 
In  closed  wounds  and  in  septicemia,  vaccines  do  not  appear  to 
give  good  results. 

TREATMENT  OF  INFECTED  SUPPURATING  WAR  WOUNDS. 

— Rutherford  Morison.    Lancet,  London,  1916,  cxci,  p.  268. 

The  method  advocated  by  the  author  is  as  follows:  The 
operative  field  and  wound  are  first  carefully  cleansed  with  1 :20 


ABSTRACTS  OF  WAR  SURGERY  107 

carbolic  lotion.  The  wound  is  then  filled  with  a  paste  made  as 
follows :  bismuth  subnitrate  1  ounce  ;  iodoform  2  ounces ;  sufficient 
paraffin  liquid  to  make  a  thick  paste.  The  wound  is  then  covered 
with  sterile  gauze  and  the  superficial  dressing  only  is  changed 
as  often  as  necessary  according  to  the  amount  of  the  discharge. 
The  results  have  been  uniformly  satisfactory. 

TREATMENT  OF  INFECTED  WOUNDS  BY  PHYSIOLOGICAL 
METHODS.— A.  E.  Wright,  Brit.  Med.  Jour.,  1916,  i,  p.  793. 

The  treatment  of  septic  war  wounds  divides  itself  naturally 
into  three  therapeutic  procedures:  (1)  The  aim  is  to  promote 
the  destruction  of  the  microbes  deep  in  the  tissues,  reestablish 
normal  conditions  in  the  tissues  and  prevent  spreading  of  the 
infection.  (2)  When  the  deep  infection  has  been  exterminated 
the  surface  infection  must  be  dealt  with.  (3)  The  processes  of 
repair  are  promoted,  tissues  brought  together,  and  the  denuded 
surfaces  covered. 

The  ordinary  antiseptic  combines  with  every  kind  of  albumen, 
thereby  losing  its  bactericidal  and  penetrating  power.  In  the 
customary  treatment  of  wounds,  drainage  is  entirely  inadequate. 
In  tissues  of  normal  density  nothing  like  adequate  effusion  may 
be  obtained,  the  lymph  flow  being  here  rapidly  arrested  by  clot- 
ting and  desiccation.  No  steps  are  taken  to  disperse  infiltration 
or  accelerate  the  separation  of  the  sloughs  or  bring  antibacterial 
lymphs  or  phagocytes  to  the  seat  of  infection.  Lastly,  in  the 
ordinary  treatment  of  septic  wounds  not  nearly  enough  care  is 
taken  to  prevent  those  active  and  passive  movements  which  lead 
to  the  mechanical  impulsion  of  microbes  along  the  lymphatics 
and  to  autoinoculations. 

Saline  dressings  supply  a  means  for  evoking,  in  the  infected 
wound,  certain  requisite  physiological  reactions.  By  their  aid 
we  can,  while  inhibiting  bacterial  growth,  drain  the  tissues,  re- 
solve infiltration,  and  promote  the  separation  of  the  sloughs, 
besides  giving  other  assistance. 

As  to  the  physical  and  physiological  action  of  concentrated 
salt  solutions  the  following  facts  are  noted:  (1)  A  concentrated 
salt  solution  will  attract  water  which  will  carry  out  with  it  the 
whole  of  the  protein  substance  which  it  holds  in  solution.  This 
means  that  a  hypertonic  salt  solution  applied  to  tissues  lying 
bare  in  the  wound,  will  operate  as  a  lymphagogue,  drawing  out 
from  the  infected  tissues  lymph  which  has  spent  all  its  antibac- 
terial energy  and  drawing  into  the  tissues  from  the  blood  stream 


108  ABSTRACTS  OF  WAR  SURGERY 

lymph,  inimical  to  microbic  growth.  (2)  Brought  into  direct 
application  upon  leucocytes  a  hypertonic  solution  will  disintegrate 
them,  setting  free  trypsin.  (3)  It  will  inhibit  the  action  of  the 
tryptic  ferment.  (4)  It  will  inhibit  coagulation.  (5)  It  will 
inhibit  leucocytic  emigration.    (6)  It  will  inhibit  microbic  growth. 

Physiological  sodium  chloride  exerts  a  positive  chemiotactic 
effect  on  white  blood  corpuscles.  In  moderately  dilute  solution 
salt  does  not  interfere  with  the  activity  of  trypsin,  nor  does  it 
inhibit  blood  or  lymph  coagulation,  phagocytosis  or  microbic 
growth. 

By  the  time  the  patient  reaches  the  clearing  station  his  wound 
will  generally  have  assumed  the  character  of  a  lymph-bound, 
infiltrated,  and  sloughing  wound.  By  free  incision  and  the  ap- 
plication of  hypertonic  saline  solution  a  fresh  supply  of  lymph 
will  be  drawn  into  the  wound  and  conditions  established  in  the 
depth  of  the  wound  favorable  to  the  extermination  of  the  mi- 
crobic infection  and  in  the  cavity  of  the  wound  conditions  which 
will  restore  microbic  growth.  As  the  salt  solution  becomes 
more  dilute  the  tryptic  ferment  comes  into  action  and  goes  about 
its  work  of  cleaning  digestion.  At  the  same  time  leucocytes 
emigrate  into  the  wound  and  the  discharge  begins  to  assume  a 
purulent  character. 

In  cases  of  gas  gangrene,  streptococcic  cellulitis,  infection  of 
joints,  continuous  lymph-lavage  is  acquired  and  necessitates  the 
continuous  use  of  hypertonic  salt  solution.  So  also  in  cases 
which  are  threatened  with  secondary  hemorrhage  and  it  is  very 
important  to  prevent  any  tryptic  action. 

The  author  goes  into  detail  as  to  the  method  of  making  proper 
solutions,  and  the  method  of  applying  hypertonic  salt  solution 
so  that  it  may  produce  an  adequate  lymphagogic  action,  and 
afterwards  provide  opportunity  for  digestive  cleansing  of  the 
wound.  Several  methods  of  supplying  hypertonic  salt  solution 
are  described.  The  author  does  not  favor  the  use  of  small  sacs 
containing  sodium  chloride. 

As  regards  the  external  covering  to  go  over  the  wet  salt  dress- 
ings, the  author  favors  the  use  of  an  impervious  covering  to  pre- 
vent the  drying  up  of  the  dressing  and  the  subsequent  deposi- 
tion of  sodium  chloride  in  the  dressings. 

A  septic  wound  requires  to  be  dressed  under  two  quite  different 
conditions :  (1)  it  requires  redressing  as  soon  as  tryptic  ferment 
is  set  free  in  the  cavity  of  the  wound;  (2)  again,  every  septic 
wound  should  be  redressed  as  soon  as  it  is  lymph-bound. 

The  usual  method  of  showing  preference  in  the  dressing  of 


ABSTRACTS  OP  WAR  SURGERY  109 

wounds  where  the  dressings  have  become  saturated  with  dis- 
charges, the  author  believes,  is  wrong.  A  gravely  wounded  man 
may  have  unsoiled  dressings.  It  should  be  definitely  determined 
that  the  wound  is  not  lymph-bound  and  the  poisons  being  ab- 
sorbed into  the  system. 

In  order  to  prevent  autoinoculations  and  a  dispersal  of  septic 
infection  along  the  lymphatic  channels  great  care  should  be  taken 
in  the  handling  of  infected  extremities  and  in  the  moving  of  pa- 
tients so  as  to  prevent  dissemination  of  infected  material.  Espe- 
cially is  this  true  in  cases  of  compound  fractures  when  too  often 
the  assistant  is  allowed  to  use  the  lower  part  of  the  extremity  as 
a  lever  to  support  the  limb. 

A  moist  dressing  with  an  impervious  covering  is  usually  the 
best  method  for  caring  for  wounds  in  preparation  for  long  jour- 
neys during  which  they  can  not  be  kept  under  close  observation. 

The  method  of  correcting  certain  undesirable  after-effects 
which  may  supervene  upon  the  ill-considered  or  too  long  con- 
tinued use  of  hypertonic  salt  solutions;  and  indications  as  to 
when  the  hypertonic  salt  solution  ought  to  be  discarded  in  favor 
of  a  weaker  solution  is  discussed  and  several  conditions  are  de- 
scribed in  great  detail  which  may  arise  following  too  prolonged 
use  of  hypertonic  sodium  chloride. 

Physiological  salt  solution  is  used  in  the  destruction  of  the 
surface  infection. 

As  to  the  final  stages  in  the  treatment  of  the  wound,  secondary 
suture  is  always  to  be  desired  if  the  wound  can  be  made  suffi- 
ciently clean.  Careful  observation  is  necessary  for  at  least  a 
week  afterward. 


EXPERIENCES   OF  A   CONSULTING   SURGEON. — Enderlen 
Beitr.  z.  klin.  Chir.,  1916,  xcviii,  p.  419. 

Enderlen  gives  his  experiences  of  German  war  surgery  from 
his  diary  notes.  In  the  early  part  of  the  war,  the  conservative 
treatment  of  wounds  was  found  to  be  unsuccessful  and  after 
October,  1914,  active  treatment  was  instituted  in  lieu  of  it. 

Gas  phlegmons,  or  gas  burns  as  they  are  called  by  Fraenkel, 
were  seen  not  only  in  the  superficial  but  in  the  deeper  tissues,  and 
seemed  to  result  from  all  kinds  of  wounds.  In  the  lighter  epi- 
fascial  phlegmons  incisions  and  bandages  soaked  with  hydrogen 
peroxide  or  acetic  acid,  and  oxygen  insufflation  generally  suf- 
ficed ;  but  in  the  more  serious  cases  and  deep  involvement  ampu- 
tation of  limbs  was  necessary. 


110  ABSTRACTS  OF  WAR  SURGERY 

During  1914,  Enderlen  lost  27  out  of  34  cases  of  tetanus,  al- 
though all  the  usual  means  were  used.  The  scarcity  of  tetanus 
at  the  present  time  is  due  to  prophylactic  injection. 

Cranial  wounds  since  October,  1914,  have  been  reexamined,  and 
active  measures  instituted.  Drainage  and  suturing  have  given 
good  results.  In  the  case  of  chest  wounds  the  thorax  was  closed 
when  possible.  In  larger  defects  of  the  chest  wall  the  lungs  were 
sutured  in  to  prevent  mediastinum  depression.  Autopsy  in  two 
cases  showed  completely  collapsed  lungs  and  empyema.  Hence, 
it  is  best  before  closing  the  chest  cavity  to  inflate  the  lung  by 
simple  pressure. 

Enderlen  operated  from  the  beginning  in  intestinal  gunshot 
wounds  and  had  67  successful  cases  out  of  154.  After  ten  hours, 
if  not  operated,  the  chances  of  success  are  slight.  Liver  and 
kidney  injuries  are  better  adapted  for  conservative  treatment. 
Intraperitoneal  bladder  injuries  are  mostly  fatal.  Extraperi- 
toneal bladder  injuries  can  usually  be  managed  with  continuous 
catheterization.  Urethrotomy  is  generally  called  for  in  uretheral 
injuries. 

In  spinal  region  injuries  the  outlook  is  not  entirely  hopeless. 
Treatment  should  be  instituted  even  though  the  prognosis  is 
gloomy.  In  the  lumbar  spine  the  results  give  even  better  promise. 
Enderlen  mentions  a  few  cases  of  sectioned  nerves  which  were 
sutured  with  good  anatomic  result. 

For  vascular  injuries  Enderlen  has  used  ligatures,  suturing, 
and  transplantation.  The  ligature  is  generally  confined  to  the 
smaller  vessels,  but  suture  will  be  used  in  the  femoral,  popliteal, 
carotid,  and  other  large  vessels  as  in  these  cases  the  ligature  of 
the  vessel  is  liable  to  cause  gangrene  in  the  limb.  In  the  brachial 
and  femoralis  Enderlen  both  sutured  and  transplanted  with  good 
results. 

THE  ADVANCED  SURGICAL  POST.— J.  and  P.  Fielle,  Rev.  de 
chir.,  1916,  xxxv,  p.  302. 

The  authors  believe  the  establishment  of  advanced  surgical 
posts  in  the  battle  line  is  necessary.  In  such  a  post  properly 
constructed  and  protected  the  surgeon  can  operate  safely  and 
calmly.  Such  operations  are  not  only  acceptable,  but  are  de- 
manded by  the  wounded.  The  utility  of  such  posts  as  regards 
hemorrhagic  injuries  is  unquestionable. 

In  other  conditions,  such  as  abdominal  wounds,  early  interven- 
tion is  the  essential  condition  for  success.    For  such  the  advanced 


ABSTK  \<"I'S   OF    \V  \i!    SURGERY  1  1  I 

post  is  necessary.  Amputations  must  yield  to  early  resections. 
Infection  is,  next  to  hemorrhage,  the  cause  of  numerous  amputa- 
tions which  can  be  avoided  by  care  and  attention  in  the  advanced 
post.  Where  the  wounded  can  not  be  despatched  every  day  to 
clearing  hospitals,  the  advanced  surgical  post  is  indispensable. 

Details  are  given  of  84  operations  carried  out  in  such  a  post, 
also  of  the  necessary  accommodations,  construction,  and  equip- 
ment. 

THE  WORKING  OF  A  CLEARING  AMBULANCE.— A.  Latarjet. 
Lyon  chir.,  1916,  xiii,  p.  166. 

The  author  gives  very  interesting  particulars  of  the  surgical 
work  done  in  a  field  ambulance  during  a  period  of  offensive. 
To  this  ambulance  service  was  assigned  the  work  of  receiving 
all  the  wounded  from  an  army  corps.  During  the  5  days  of  at- 
tack, 9,328  wounded  were  disposed  of.  Of  these,  5,011  were 
slightly  wounded,  and  4,317  had  more  or  less  grave  wounds. 

Of  the  5,011  slightly  wounded,  656  were  immediately  dispatched 
to  the  clearing  hospital.  The  remaining  4,355  were  examined 
and  had  their  wounds  dressed.    These  wounds  comprised : 

Head  and  neck 732 

Thorax   354 

Abdomen   102 

Upper  limbs   1600 

Lower  limbs   1330 

Multiple  wounds 46 

Shock   191 

After  the  wounds  were  dressed  these  men  were  sent  on  to  the 
clearing  hospitals  at  the  base.  The  4,317  injuries  of  the  seriously 
wounded  were  as  follows : 

Head 516 

Neck  96 

Thorax   531 

Abdomen   267 

Upper  limb    816 

Lower  limb   1443 

Spine 18 

Genital  organs   24 

Multiple  wounds 565 

Gas  intoxication,  etc 41 

Of  these  4,317,  108  died  during  the  period  within  five  days, 


112  ABSTRACTS  OF  WAR  SURGERY 

mostly  a  few  hours  after  arrival  and  without  intervention.  Sixty- 
three  died  while  being  conveyed  from  the  field  to  the  ambulance. 
The  total  immediate  mortality  was  254. 

Of  the  531  thoracic  wounds,  176  were  shell  wounds,  132  bullet, 
and  20  bomb  wounds.  Twenty-three  died  between  the  first  and 
third  day  from  hemorrhage  or  shock ;  16  died  from  the  fourth  to 
twelfth  day.  Of  the  267  abdominal  wounds,  124  were  pene- 
trating. Two  hundred  and  fifty-four  of  the  wounded,  intrans- 
portable  and  inoperable,  were  hospitalized  on  the  spot.  The 
others  were  dispatched  to  the  clearing  base  hospitals,  either  by 
auto  or  train. 

Hospitalization  within  a  few  hours  of  injury,  immediate  large 
evacuation  of  wounds,  and  evacuation  only  toward  the  interior 
when  the  patients  are  in  a  fair  way  to  recover  are  the  ends  to 
be  sought  if  lamentable  consequences  are  to  be  avoided. 

INTERALLIED  SURGICAL  COMMISSION  ON  TREATMENT 
OF  WOUNDS.— Bull,  med.,  Paris,  1917,  p.  125. 

The  Surgical  Commission  appointed  by  the  allied  nations  to 
discuss  the  treatment  of  wounds,  of  which  Professor  Turner  was 
appointed  president,  arrived  at  the  following  conclusions  at  its 
first  meeting  March  15,  1917 : 

1.  It  is  desirable  that  the  organization  of  service  be  so  ar- 
ranged as  to  permit  a  continuity  of  surgical  direction  in  the 
treatment  of  the  wounded. 

2.  In  the  fighting  posts  and  especially  in  the  trenches,  surgery 
should  be  reduced  to  the  minimum.  It  must  be  limited  to  dealing 
with  complications  which  may  be  immediately  mortal  and  to  the 
cleansing  of  wounds.  The  wound  should  neither  be  explored 
nor  irrigated.  It  should  simply  be  protected  by  a  dry  aseptic 
or  antiseptic  dressing. 

3.  It  is  essential  to  transport  the  wounded  as  quickly  as  pos- 
sible to  one  of  the  large  hospitals  at  the  front  which  are  situated 
at  from  10  to  20  kilometers  from  the  firing  lines. 

4.  It  is  advantageous  that  each  of  these  hospitals  should  have 
one  or  several  attached  advanced  annexes,  nearer  to  the  firing 
line,  so  as  to  quickly  receive  certain  classes  of  severely  wounded, 
those  in  shock  or  attacked  by  severe  hemorrhage,  thoracic,  or 
abdominal  injury,  etc. 

5.  Generally  speaking  war  wounds  should  be  considered  as 
contaminated  or  infected. 

6.  The  object  of  treatment  should  be:  (1)  to  prevent  infec- 


ABSTRACTS  OF  WAR  SURGERY  113 

tion  of  the  wound  if  only  contaminated,  or  to  obtain  steriliza- 
tion if  infection  is  evident;  (2)  to  permit  suturing  when  clinical 
sterilization  has  been  obtained. 

7.  Wide  opening  up  of  the  wound  with  resection  of  contused 
tissue,  removal  of  debris  of  clothing,  etc.,  should  be  considered 
a  matter  of  course,  with  exceptions  only  in  certain  cases  which 
can  be  rigidly  supervised. 

8.  After  such  intervention  immediate  suture  is  capable  of 
giving  favorable  .results,  especially  in  articular  wounds.  It 
should  be  executed  only  in  cases  in  which  the  wound  is  but  of  a 
few  hours'  duration,  maximum  8  hours,  and  when  the  surgeon 
can  continue  supervision  of  the  patient  for  fifteen  days. 

9.  If  immediate  suture  is  not  done,  secondary  suture  must  be 
resorted  to  when  sterilization  of  the  wound  is  sufficiently  evident 
clinically. 

10.  Evolution  of  the  wound  should  be  systematically  con- 
trolled by  periodical  bacteriological  examinations  which  will  al- 
low the  construction  of  a  microbian  curve  and  determine  the 
degree  of  sterilization. 

11.  When  there  is  necessity  of  evacuating  patients  whose 
wounds  have  been  opened  up  and  excised  a  dressing  should  be  ap- 
plied, the  action  of  which  would  continue  during  all  the  time  of 
transport.    There  is  need  of  research  in  this  respect. 

12.  Several  methods  of  progressive  sterilization  of  wounds 
exist,  which  permit  secondary  suture  regularly. 

THE   BACTERIOLOGY   OF   SEPTIC   WOUNDS.— A.  Fleming. 
Lancet,  London,  1915,  clxxxix,  p.  638. 

The  flora  of  infected  war  wounds  as  determined  in  this  war, 
differs  from  that  of  infected  wounds  in  civil  practice.  The 
wounds  examined — mostly  bullet  and  shell  wounds — were  all  in- 
fected by  the  projectiles  first  passing  through  dirty  clothing 
covered  with  mud.  Shreds  of  clothing  were  commonly  found 
in  the  wounds,  and  pieces  of  clothing  of  considerable  size  were 
found  in  the  larger  wounds.  The  presence  of  blood  and  con- 
tusion in  the  wound  area  augmented  the  tendency  to  the  de- 
velopment of  infection. 

The  organisms  found  in  wounds  are  divided  in  three  groups : 
(1)  spore-bearing  microbes  of  fecal  origin;  (2)  nonspore-bearing 
microbes  also  of  fecal  origin;  and  (3)  pyogenic  cocci. 

The  first  group  includes  bacillus  tetani,  bacillus  aero  genes  cap- 
sulatus  of  Welch  and  certain  putrefactive  organisms  referred  to 


U4  ABSTRACTS  OF  WAR  SURGERY 

as  bacilli  X  and  G.  The  habitat  of  this  group  is  fecal  soil,  or 
fecal  accumulations  from  animal  and  human  excreta.  The  non- 
spore-bearing  organisms  of  fecal  origin  are  the  streptococcus, 
bacillus  proteus,  and  bacillus  coli  group,  the  streptococcus  being 
the  most  important.  It  is  found  in  nearly  all  wounds  at  a  late 
stage.  The  third  group  comprises  the  streptococcus  and  staphy- 
lococcus. The  latter  is  not  commonly  found  in  animal  feces;  it 
occurs  in  the  later  stages  of  a  wound,  and  it  probably  invades  it 
from  the  surrounding  skin  in  which  it  is  normally  found. 

The  odor  of  the  cultures  of  bacilli  X  and  G  is  very  putrid; 
they  are  gas  producing;  they  are  not  pathogenic  for  guinea 
pigs. 

To  determine  the  relationship  between  the  infections  in  wounds 
and  the  bacteria  on  the  clothing,  12  samples  of  the  latter  were 
taken  from  the  wounded  on  arrival  at  the  base.  Pieces  an  inch 
square  were  cut  away  from  the  location  of  the  wounds  and 
were  planted  into  broth  tubes  and  cultivated  aerobically  and 
anaerobically. 

Bacillus  aerogences  capsulatus  was  found  in  10  of  the  speci- 
mens ;  bacillus  tetani  in  4 ;  streptococcus  in  5 ;  and  staphylococcus 
in  4. 

From  a  study  of  the  bacterial  flora  of  the  wounds  one  recog- 
nizes three  phases.  If  we  take  a  compound  fracture  of  the  femur 
during  the  first  week,  the  discharge  is  a  dark  reddish-brown  fluid, 
foul-smelling,  consisting  of  blood  more  or  less  altered  by  the 
growth  of  fecal  organisms  which  constitute  the  primary  infec- 
tion. In  this  stage,  the  spore-bearing  anaerobes  and  streptococci 
are  mostly  present.  The  second  phase  represents  a  transition 
between  the  primary  anaerobic  infection  and  the  infection  with 
pyogenic  cocci  when  the  discharge  becomes  purulent,  next  less 
marked,  and  finally  disappearing  altogether.  This  stage  lasts 
from  two  to  three  weeks.  The  third  phase  is  at  the  end  of  the 
third  week  during  which  the  fecal  elements  of  infection  disap- 
pear and  we  have  a  simple  infection  of  pyogenic  cocci,  staphylo- 
cocci, and  streptococci. 

A  bacteriological  study  of  a  number  of  severe  wounds  shows 
that  the  bacillus  aerogenes  capsulatus,  associated  with  the  strep- 
tococcus and  a  few  staphylococcus  albus,  produced  gas  gangrene 
on  about  the  third  day.  The  bacillus  of  Welch  is  the  most  prom- 
inent organism  in  the  pus  until  the  eighth  day  when  coliform 
bacilli,  like  proteus  and  pyocyaneous  appear  in  the  wound.  A 
few  Welch  bacilli  may  persist  in  the  wound  until  the  thirty- 
second  day. 


ABSTRACTS  OF  WAR  SURGERY  115 

The  author  finds  that  there  is  no  difference  noticeable  in  the 
flora  of  wounds  with  gas  gangrene  and  those  in  which  there  is 
no  clinical  manifestation  of  this  infection.  The  onset  of  the  in- 
fection by  the  Welch  bacillus  is  not  so  much  due  to  the  nature 
of  the  infection  as  it  is  to  the  mechanical  condition  of  the  wound, 
such  as  the  presence  or  absence  of  free  drainage. 

The  tetanus  bacillus  was  found  in  the  clothing  of  the  wounded 
soldiers  and  in  a  large  number  of  the  discharges  from  the  wounds. 
In  most  of  these  cases  the  wounds  were  serious,  with  heavy  in- 
fection from  other  organisms.  It  was  found  in  company  with  the 
Welch  bacillus  in  wounds  showing  infection  from  the  latter,  and 
a  few  of  such  cases  actually  developed  into  tetanus. 

Blood  cultures  from  a  number  of  compound  fractures  with  per- 
sistent high  fever  were  made,  and  in  25  per  cent  of  such  cases 
a  streptococcus  was  isolated.  Streptococci,  as  already  deter- 
mined in  civil  practice,  are  responsible  for  septicemic  conditions. 
In  one  case  a  pure  culture  of  bacillus  coli  was  isolated.  The 
streptococci  recovered  from  the  blood  were  all  of  the  "strep- 
tococcus longus"  type. 

One  striking  feature  of  the  discharges  from  the  wounds  was 
the  extraordinary  amount  of  phagocytosis.  It  was  uncommon 
to  see  pus  in  which  large  numbers  of  the  organisms  had  not  been 
appropriated  by  the  leucocytes.  Cultures  from  this  pus  were 
found  quite  sterile,  showing  that  the  leucocytes  had  not  only  in- 
gested the  cocci,  but  had  apparently  killed  them.  This  phagocy- 
tosis leads  one  to  believe  that  the  resistance  to  infection  in  war 
wounds  is  very  great,  as  compared  to  the  resistance  found  in  in- 
fection in  civil  practice,  where  infection  occurs  more  or  less 
spontaneously  in  individuals  possessed  with  lower  resistance. 
In  civil  practice  it  should  be  remembered  that  the  infecting  agent 
has  often  acquired  increased  virulency  in  passing  from  one  in- 
dividual to  another ;  whereas,  the  virulency  of  the  agents  infect- 
ing war  wounds  has  been  more  than  likely  attenuated  by  the 
unfavorable  surroundings  under  which  they  were  existing,  the 
severity  of  the  wound  infections  being  merely  the  result  of  the 
destruction  of  tissues  marked  by  the  presence  of  laceration,  con- 
tusion, etc.,  which  furnish  an  admirable  culture  medium  for  the 
bacteria  out  of  reach  of  the  natural  protective  forces  of  the  body. 
It  is  suggested  by  the  author  that  if  all  devitalized  tissue  could 
be  completely  removed  infections  would  sink  into  insignificance. 
Since  this  can  not  be  done  it  is  incumbent  to  practice  efficient 
drainage,  remove  blood-clot,  and  do  all  that  is  possible  to  di- 
minish the  amount  of  culture  medium  upon  which  the  bacteria 


116  ABSTRACTS  OF  WAR  SURGERY 

are  developing.  Along  with  this  wound  treatment  the  patient's 
resistance  should  be  maintained  at  a  high  level  by  the  administra- 
tion of  an  appropriate  vaccine.  In  this  connection  Fleming  thinks 
that  it  is  of  advantage  to  administer  in  every  case  of  infection 
streptococcus  vaccine  in  small  doses  of  about  1  to  5  millions  every 
five  or  six  days. 

CICATRIZATION  OF  WOUNDS;  THE  USE  OF  CHLORAMINE- 
T  PASTE  FOR  THE  STERILIZATION  OF  WOUNDS.— M. 

Daufresne.    Jour.  Exper.  Med.,  1917,  xxvi,  p.  91. 

The  author  draws  attention  to  the  fact,  as  shown  in  a  previous 
communication,  that  a  wound  cicatrizes  rapidly  if  the  surface 
is  sterile,  and  if  it  is  more  or  less  infected,  the  rate  of  cicatriza- 
tion is  slow  or  the  wound  enlarges.  In  order  to  obtain  a  con- 
venient method  for  the  sterilization  of  wounds,  Daufresne  has 
endeavored  to  prepare  an  antiseptic  paste  which  will  retain  its 
aseptic  properties. 

It  has  been  found  that  ointments  and  other  fatty  substances 
are  inefficient  when  applied  to  wounds,  because  the  bacteria  and 
antiseptic  are  covered  with  fatty  material  which  isolates  them 
from  each  other  and  permits  the  bacteria  to  multiply  freely. 
Hence  the  antiseptic  paste  must  be  soluble,  and  the  bactericidal 
agent  must  be  embodied  in  a  substrate  suitably  chosen  so  that 
the  whole  constitutes  a  system  physically  homogeneous.  On  the 
other  hand,  the  author  states,  to  enable  the  antiseptic  to  act  con- 
tinuously the  base  should  be  absorbed  slowly  by  the  tissues  in 
order  to  renew  the  surface  of  contact  constantly.  Neutral  sodium 
stearate  was  used  for  this  purpose  because  of  the  facility  with 
which  it  is  made  antiseptic  and  also  because  it  is  not  injurious 
to  the  tissues.  As  he  states,  it  is  well  known  that  the  slightly 
soluble  sodium  soaps,  far  from  being  irritating  agents,  are,  on 
the  contrary,  soothing.  Moreover,  they  give  pastes  sufficiently 
plastic  for  the  dressing  of  wounds.  One  of  Dakin's  chloramines 
was  selected  as  the  bactericidal  agent,  and  after  many  trials  the 
following  formula  was  used  by  Daufresne. 

Neutral   sodium  stearate 86  gm. 

Chloramine-T  4-10  gm. 

Distilled  water 1000  ccm. 

Of  the  less  soluble  sodium  soaps  he  considers  it  essential  to 
choose  those  derived  from  saturated  fatty  acids  and  not  having 
double  ethylene  linkages.     The  presence  of  such  groups  which 


ABSTRACTS  OF  WAR  SURGERY  117 

readily  take  up  the  elements  of  hypochlorous  acid  (HCIO)  he 
believes,  causes  a  rapid  disappearance  of  chloramine.  On  the 
other  hand,  stearic  acid  is  a  product  of  sufficient  purity  and  is 
easily  procured ;  its  sodium  salt  obtained  by  boiling  the  calculated 
amount  diluted  with  caustic  soda  is  aseptic. 

Daufresne  chose  as  an  antiseptic  to  combine  with  the  sodium 
stearate  one  of  the  substances  studied  by  Dakin,  known  as  chloram- 
ine-T,  which  is  the  sodium  salt  of  toluene  sodium  p-sulfochloram- 
ide.  His  reasons  for  choosing  this  substance  were  its  high 
bactericidal  power,  the  absence  of  caustic  action  on  the  skin, 
the  possibility  of  an  exact  estimation  of  its  strength,  and  its 
stability  at  a  high  temperature,  which  allows  the  substances  to 
dissolve  in  a  boiling  solution  of  stearate.  The  question  of  using 
sodium  hypochlorite  was  not  considered  because  this  product 
changes  rapidly  under  the  influence  of  heat,  and  especially  be- 
cause of  the  sensitiveness  of  soap  solutions  to  the  action  of 
electrolytes. 

The  principal  disadvantage  of  this  paste  is  its  poor  power  of 
preservation ;  numerous  trials  showed  that  10  per  cent  of  chlora- 
mine-T  disappeared  per  month,  the  author  states.  Substances 
which  might  have  rendered  the  paste  more  stable  were  either  in- 
efficient or  lessened  its  keeping  properties.  The  stability  of  the 
paste  is  limited  by  the  stability  of  the  solution  of  chloramine-T 
because  the  antiseptic  is  in  solution  in  the  paste. 

Daufresne  concludes  that  Dakin 's  toluene  sodium  p-sulfochlora- 
mide,  mixed  with  sodium  stearate,  forms  a  paste  sufficiently 
active  and  stable  to  be  used  in  the  treatment  of  wounds. 

CICATRIZATION  OF  WOUNDS;  STERILIZATION  OF 
WOUNDS  WITH  CHLORAMINE-T.— A.  Carrel,  and  A. 
Hartmann,  Jour.  Exper.  Med.,  1917,  xxvi,  p.  95. 

The  authors  draw  attention  to  a  previous  article  in  which  it 
was  shown  that  the  presence  of  bacteria  at  the  surface  of  a 
wound  retards  the  normal  process  of  cicatrization,  and  accord- 
ing to  the  nature  and  size  of  the  infection,  the  curve  represent- 
ing cicatrization  deviated  from  the  calculated  curve.  In  order 
to  investigate  the  substances  which  are  capable  of  influencing 
tissue  repair,  they  state,  it  is,  therefore,  imperative  that  the 
wound  should  be  kept  in  an  aseptic  condition,  as  no  specific 
influence  on  the  progress  of  healing  could  be  attributed  to  the 
substance  experimented  with  unless  the  possible  action  of  in- 
fection was  entirely  eliminated. 


118  ABSTRACTS  OF  WAR  SURGERY 

Sterilization  of  a  wound  has  been  found  to  be  easily  effected 
by  the  application  of  Dakin's  hypochlorite  solution  at  the  sur- 
face of  the  tissues  under  appropriate  conditions  of  concentra- 
tion and  duration.  In  the  experiments  described  in  this  article, 
the  authors  attempted  to  simplify  the  method  by  substituting 
for  the  instillations  of  Dakin's  hypochlorite  solution  a  paste 
designed  gradually  to  yield  up  to  the  tissues  one  of  Dakin's 
chloramines  contained  therein,  and  investigations  were  under- 
taken to  ascertain  whether  this  paste  would  be  able  to  keep 
a  sterile  wound  in  an  aseptic  condition,  as  well  as  to  sterilize 
an  infected  wound,  and  whether  it  would  retard  tissue  repair. 

The  influence  of  sodium  stearate  containing  4  parts  per  1,000 
of  chloramine-T  was  first  tested  on  surface  wounds  which  had 
been  rendered  almost  aseptic  by  instillations  of  Dakin's  hypo- 
chlorite solution,  and  in  the  first  experiment  a  comparison  was 
made  of  the  effect  on  the  bacteriological  condition  of  a  slightly 
infected  wound  of  sodium  stearate  alone,  and  of  sodium  stearate 
containing  4  parts  per  1,000  of  chloramine-T.  The  authors' 
observation  showed,  on  the  one  hand,  that  sodium  stearate  had 
no  effect  on  a  slightly  infected  wound,  and,  on  the  other  hand, 
that  sodium  stearate  containing  4  parts  per  1,000  of  chloramine- 
T,  produced  surgical  asepsis.  The  bacteria  disappeared  com- 
pletely from  the  films  taken  from  the  portions  of  the  wound 
treated  with  chloramine-T;  whereas  they  were  present  in  all 
the  films  from  the  part  not  so  treated.  Experiments  were 
then  undertaken  to  attempt  to  maintain  in  an  aseptic  condi- 
tion wounds  which  had  been  rendered  surgically  sterile  at  the 
beginning  of  treatment. 

Sodium  stearate,  the  authors  found,  had  no  effect  upon  the 
bacteriological  condition  of  a  wound,  but  the  addition  of  4 
parts  per  1,000  of  chloramine-T  rendered  it  antiseptic.  Their 
first  experiment  enabled  them  to  compare  the  action  of  sodium 
stearate  alone  with  that  of  sodium  stearate  containing  4  parts 
per  1,000  of  chloramine-T.  Wounds  which  had  been  previously 
sterilized  could  be  maintained  in  an  aseptic  condition  by  4  parts 
per  1,000  of  chloramine-T,  although  in  some  cases  reinfection 
occurred.  For  this  reason  the  concentration  of  chloramine-T 
was  increased. 

Surface  wounds,  deep-seated  wounds,  and  osseous  cavities, 
which  had  previously  been  either  completely  or  almost  com- 
pletely sterilized,  were  maintained  for  days  and  even  weeks 
in  a  condition  of  surgical  asepsis  by  the  use  of  a  paste  contain- 


ABSTRACTS  OF  WAR  SURGERY  119 

ing  7  and  10  parts  per  1,000  of  chloramine-T.  Slightly  in- 
fected wounds  were  sterilized  in  the  same  manner. 

Next,  the  authors  attempted  to  sterilize  wounds  which  were 
suppurating  and  more  or  less  infected,  and  in  some  cases  ac- 
companied by  fracture.  This  attempt  was  probably  successful 
because  the  wounds  used  for  the  experiments  showed  but 
slight  quantities  of  secretions  and  only  a  shallow  layer  of 
necrotic  tissue.  It  was  useless  to  attempt  to  sterilize  severely 
infected  wounds  with  a  paste,  for  the  volume  of  chloramine-T 
that  could  be  applied  was  too  limited.  A  large  volume  of  an 
active  substance  was  required  to  sterilize  a  wound  which 
secreted  great  quantities  of  pus,  for  owing,  on  the  one  hand, 
to  the  dilution  of  this  substance  with  the  secretions,  and,  on 
the  other,  to  its  combination  with  the  other  proteins  contained  in 
the  pus,  the  concentration  of  the  antiseptic  was  rapidly  dimin- 
ished. For  those  reasons  the  authors  considered  it  essential 
that  the  antiseptic  solution  should  be  constantly  renewed,  so 
that  the  concentration  would  be  sufficiently  strong  to  effect 
the  destruction  of  the  bacteria.  Therefore,  the  chloramine-T 
they  found,  could  not  sterilize  a  severely  infected  wound. 

The  concentration  of  the  active  substance  contained  in  a 
paste,  they  state,  must  at  the  same  time  be  sufficiently  weak 
to  be  innocuous  to  the  tissues,  and  should  not  exceed  15  parts 
per  1,000.  Thus,  it  was  evident  that  if  the  secretions  from 
the  wounds  were  abundant,  the  substance  could  exert  its  ac- 
tion upon  the  microorganisms  for  the  space  of  only  a  few 
hours.  For  this  reason  the  chloramine  paste,  they  believe, 
should  be  applied  only  under  the  conditions  specified  in  their 
experiments,  that  is,  in  connection  with  moderately  infected 
wounds  which  have  been  carefully  washed  with  sodium  oleate, 
and  possess  but  slight  quantities  of  secretion.  Under  these  con- 
ditions the  chloramine  paste  affected  the  complete  disappear- 
ance of  the  bacteria  and  maintained  the  sterility  thus  secured 
for  as  long  a  time  as  wished.  If  the  technic  followed  in  the  dress- 
ing was  not  exactly  as  described  by  the  authors,  reinfection  oc- 
curred. If  applied  in  this  manner  the  chloramine  paste  was  not 
injurious  to  the  tissues,  for  the  cicatrization  curves  of  the  wounds 
thus  treated  showed  but  slight  modifications  from  the  calculated 
curves. 

Chloramine  paste  makes  it  possible,  therefore,  the  authors 
conclude,  to  keep  wounds  sufficiently  free  from  microorganisms 
so  that  the  effect  of  substances  which  are  believed  to  influence 
cicatrization  can  be  studied.     Under  the  conditions  of  their  ex- 


120  ABSTRACTS  OF  WAR  SURGERY 

perhnents  the  paste  maintained  the  asepsis  of  a  wound  already 
sterile  and  sterilized  an  infected  wound,  and  under  the  same 
conditions  it  caused  no  apparent  modification  of  the  cicatriza- 
tion curve  of  an  aseptic  wound. 

STERILIZATION  OF  WAR  WOUNDS.— Dehelly  and  Dumas. 
Presse  med.,  1916,  p.  203. 

The  authors  give  the  technic  of  their  treatment  for  the 
rapid  disinfection  of  war  wounds.  They  use  a  solution  of  1 :200 
of  hypochlorite  of  sodium  prepared  according  to  Dakin's  method. 
The  special  technic  for  obtaining  access  to  the  deeper  parts  of 
wounds  is  described.  The  treatment  comprises  surgical  inter- 
vention, continuous  instillation,  and  careful  after-treatment. 
Intervention  is  done  aseptically  as  under  operative  conditions, 
and  following  this  it  is  necessary  that  all  parts  of  the  wound  be 
kept  in  permanent  contact  with  the  antiseptic  solution.  For 
closure  of  the  wound  the  authors  prefer  adhesive  strips  to  su- 
tures. 

Of  155  cases  of  extensive  wounds  due  to  shells,  bombs,  and 
mines  which  have  been  treated  by  this  method,  135,  or  87.4  per 
cent,  have  closed.  Of  these,  119  were  cicatrized  in  less  than  30 
days.  Twenty-five  of  the  155  cases  were  complicated  with  frac- 
tures and  of  these  18  were  cicatrized  in  less  than  30  days. 

CONSIDERATIONS  ON  SOME  WAR  INJURIES  AFTER 
EIGHTEEN  MONTHS  OF  CAMPAIGN.— R  Proust.  Bull, 
et  mem.  Soc.  de  chir.  de  Paris,  1916,  xlii,  p.  1270. 

Proust  submits  some  general  ideas  gained  from  eighteen 
months'  experience  in  field  ambulances.  From  May,  1915,  to 
February,  1916,  while  in  charge  of  Surgical  Automobile  Am- 
bulance No.  1,  he  cared  for  1,800  wounded,  most  of  which  had  severe 
infected  wounds.    The  mortality  was  23  per  cent. 

In  injuries  to  veins  or  arteries  the  author  ligates  the  vessel 
some  distance  above  and  below  the  injury  and  resects  the  in- 
jured part. 

In  bone  lesions,  free  splinters  of  bone  should  be  removed,  but 
care  must  be  used  as  regards  other  lesions. 

For  articular  wounds,  Proust  believes  that  when  any  articu- 
lation is  traversed  by  a  projectile  other  than  a  bullet  the  open- 
ing must  be  largely  widened  so  as  to  ensure  drainage ;  and  cer- 
tain resections  such  as  of  the  patella  and  astragalus  may  have 


ABSTRACTS  OF  WAR  SURGERY  121 

to  be  resorted  to.  Patellectomy  has  given  15  recoveries  in  19 
grave  wounds  of  the  knee ;  16  shoulder-resections  gave  14  recov- 
eries.   Operative  indications  are  exceptional  for  nerve-resections. 

In  the  case  of  wounds  which  are  difficult  of  disinfection  even 
after  free  opening  up,  Carrel's  method,  i.e.,  intermittent  instil- 
lation of  freshly  prepared  Dakin's  solution,  has  given  the  best 
results. 

When  amputations  are  necessary  Proust  always  resorts  to 
plane  section.  In  the  1,800  wounded  treated  there  were  152 
amputations  with  a  total  mortality  of  15  per  cent,  distributed 
as  follows : 

52  thigh  amputations 47  per  cent  mortality. 

31  leg  amputations 16  per  cent  mortality. 

9  foot   amputations 18  per  cent  mortality. 

29  arm  amputations 27  per  cent  mortality. 

18  forearm  amputations 5.5  per  cent  mortality. 

The  mortality,  however,  has  decreased  under  better  conditions. 
Thus  from  June  to  July  the  mortality  was  72  per  cent,  from 
September  to  November,  32  per  cent,  from  December  to  January, 
20  per  cent. 


TETANUS 

ANTITOXIN  CONTENT  OF  THE  SERUM  OF  TETANUS 
PATIENTS.— H.  Wintz,  Mimchen.  med.  Wchnschr.,  1915, 
lxii.,  p.  1564. 

Wintz  describes  his  experiments  on  mice,  in  which  he  injected 
tetanus  toxin  and  the  serum  of  tetanus  patients  to  see  if  the 
latter  had  any  antitoxic  effect.  He  found  that  the  serum  of 
tetanus  patients  contained  antitoxin  that  was  capable  of  neutral- 
izing tetanus  toxin  in  vitro.  The  amount  of  antitoxin  varied 
with  the  stage  of  the  disease,  seeming  to  be  greatest  in  the  be- 
ginning of  convalescence.  An  amount  was  found  that  was  pro- 
tective but  not  curative  for  mice.  Practically,  however,  the 
amounts  are  so  small  that  they  give  no  hope  of  being  effective 
in  treatment. 

TREATMENT  OF  TETANUS.— T.  Kocher.  Correspondenzbl.  f. 
schweiz.  Aerzte,  1915,  xlv,  p.  1249. 

Kocher  says  there  are  three  things  to  be  considered  in  the 
treatment  of  tetanus ;  the  care  and  disinfection  of  the  wound 
as  a  prophylactic  measure,  the  prophylatic  injection  of  anti- 
toxin, and  the  use  of  magnesium  sulphate  after  the  disease  has 
developed.  He  describes  three  cases  of  his  own.  One  of  the 
patients,  an  adult,  died  of  pneumonia  after  the  tetanus  was 
controlled,  while  the  other  two,  both  children,  recovered.  One 
extremely  severe  case  in  a  boy  of  10  had  had  an  incubation  of 
six  days  and  no  prophylactic  injection  of  endotoxin  had  been 
given.  In  order  to  control  the  convulsions  four  injections  of 
the  magnesium  sulphate  had  to  be  given  the  first  day,  three  a 
day  from  the  second  to  the  tenth  day,  and  one  a  day  from 
then  on  till  the  eighteenth  day,  the  total  amount  given  in  the 
eighteen  days  being  315  gm. 

The  chief  object  of  the  magnesium  sulphate  treatment  is  to 
gain  time  until  the  body  can  form  antibodies  to  overcome  the 
tetanus  toxin.  Meltzer  and  Auer  found  that  the  maximum  dose 
was  1.5  gm.  to  1  kg.  of  body  weight,  but  Kocher  finds  that  by 
giving  it  in  fractional  doses  throughout  the  twenty-four  hours 
this  amount  can  be  given  on  from  six  to  eighteen  successive  days 

122 


ABSTRACTS  OF  WAR  SURGERY  123 

without  doing  any  harm.  The  severer  the  case  the  larger 
initial  dose  is  given,  and  it  may  be  well  to  give  it  intravenously 
for  quicker  action. 

From  his  experience  Kocher  has  come  to  the  conclusion  that 
it  is  not  necessary  to  give  the  full  dose  recommended  by  Meltzer 
and  Auer  for  producing  complete  relaxation  of  the  muscles ;  it 
is  sufficient  to  reduce  the  excitability  of  the  centers  to  such  an 
extent  that  the  convulsions  stop,  even  though  some  stiffness 
persists.  In  giving  a  dose  large  enough  for  this  purpose  there 
is  practically  no  danger  of  producing  paralysis  of  respiration. 
This  is  explained  by  the  fact  that  the  hyperexcitability  of  the 
nerve-centers  that  produce  convulsions  is  overcome  sooner  than 
their  capacity  for  reaction  to  physiological  stimuli.  Large 
amounts  of  sulphate  can  be  given  because  it  is  excreted  very 
rapidly. 

INTRASPINAL  ADMINISTRATION  OF  ANTITOXIN  IN 
TETANUS.— M.  Nicoll,  Jr.  Jour.  Am.  Med.  Assn.,  1915, 
lxiv,  p.  1982. 

The  results  obtained  in  this  series  of  cases,  taken  indiscrimi- 
nately and  regardless  of  clinical  conditions,  with  the  low  death- 
rate  of  20  per  cent,  Nicoll  claims  is  due  largely  to  the  intraspinal 
dosage.  He  recommends  the  following  method  of  administra- 
tion: 

1.  Using  3,000  to  5,000  units  an  injection  is  made  into  the 
lumbar  region  of  the  spinal  canal,  preferably  under  an  anes- 
thetic, the  volume  of  the  fluid  being  brought  up  to  10  to  15  c.c. 
by  the  addition  of  sterile  normal  saline,  the  exact  amount  being 
regulated  according  to  the  age  of  the  patient  and  the  amount 
of  spinal  fluid  withdrawn. 

2.  Ten  thousand  units  are  used  intravenously  at  the  same 
time. 

3.  The  intraspinal  dose  is  repeated  in  twenty-four  hours. 

4.  A  subcutaneous  dose  of  10,000  units  is  given  three  or  four 
days  later. 

Nicoll  strongly  urges  the  adoption  of  the  well  recognized  ad- 
juvants to  specific  treatment,  as  quiet,  subdued  light,  sedatives,  etc. 

The  histories  of  the  20  cases  treated  by  this  method  show 
that  the  period  of  incubation  ranged  from  7  to  11  days;  in  4 
of  the  cases  this  period  was  undeterminable.  In  each  case  the 
serum  was  given  intraspinally,  and,  when  the  symptoms  indi- 
cated, was  repeated  in  24  hours.     It  is  interesting  to  note  that 


124  ABSTRACTS  OF  WAR  SURGERY 

in  one  case,  a  male,  the  period  of  incubation  14  days,  after 
5,000  units  had  been  given  intraspinally  and  10,000  units  in- 
travenously, there  developed  marked  anaphylaxis,  with  general 
urticaria  and  edema  of  the  glottis  and  lungs.  This,  however, 
passed  away  after  the  administration  of  epinephrin.  Forty- 
eight  hours  afterward  the  intraspinal  dose  was  repeated  with 
less  reaction.  This  patient  is  among  the  cured.  The  four  fatal 
cases  died  suddenly,  probably  due  to  a  short  incubation  and 
the  long  delay  in  beginning  the  treatment.  One  developed 
tetanus  after  a  herniotomy,  and  though  he  was  able  to  take 
fluids  by  mouth,  and  the  convulsions  had  ceased,  he  died  from 
pulmonary  edema. 

Nicoll  believes  that  a  few  of  these  cases  would  undoubtedly  have 
recovered  if  the  intraspinal  injection  had  not  been  given,  but  the  re- 
sults obtained  are  so  much  more  favorable  than  when  large 
doses  are  used  by  the  intravenous  and  intramuscular  meth- 
ods that  he  can  not  help  but  claim  better  results  from  this 
method. 

TREATMENT  OF  TETANUS  BY  ENDONEURAL  INJECTION 
OF  ANTITETANUS  SERUM  AND  DRAINAGE  OF  THE 
NERVE.— F.  Kempf.    Arch.  f.  klin.  Chir.,  1915,  cvi,  p.  769. 

Kempf  thinks  tetanus  can  be  treated  much  more  effectively 
than  it  is  at  present  by  injecting  the  antitoxin  directly  into  the 
nerve-trunks.  He  describes  two  cases  in  which  he  has  used 
this  method.  They  were  quite  severe  cases  with  pronounced 
trismus,  difficulty  in  swallowing,  stiffening  of  the  muscles,  and 
attacks  of  dyspnea.  The  incubation  period  was  18  to  20  days, 
but  he  is  not  convinced  that  the  prognosis  is  dependent  on  the 
length  of  the  incubation  period. 

The  injections  should  be  made  into  the  nerve-trunks  of  the 
motor  nerve  of  the  limb  affected,  in  his  case  the  nerves  of  the 
axilla.  In  wounds  of  the  head  the  trifacial  and  facial  should 
be  injected,  and  in  wounds  of  the  trunk  any  anatomical  atlas 
will  show  what  nerves  supply  the  region. 

The  endoneural  injection  blocks  the  nerve  for  any  toxin  that 
may  be  produced  later  and  also  sends  antitoxin  to  the  motor 
centers  in  the  medulla  to  overcome  the  toxin  that  is  already 
anchored  there.  Endoneural  injection,  he  thinks  is  both  less 
dangerous  and  more  effective  than  subdural  injection.  The 
injection  needle  is  pushed  into  the  nerve-trunk  toward  the 
center    and    the    fluid  emptied  by  slight  pressure.     The  nerve 


ABSTRACTS  OF  WAR  SURGERY  125 

distends  and  the  distention  subsides  as  the  serum  is  taken  up 
by  the  nerve,  leaving  very  little  at  the  site  of  injection.  The 
eye  can  follow  the  progress  of  the  antitoxin  upward  in  the 
nerve. 

In  Kempf's  second  case,  in  order  to  strengthen  the  effect  of 
the  injection,  he  drained  the  nerve,  the  object  being  to  drain 
the  toxin  from  the  body.  He  used  metal  tubes  fastened  with 
catgut  into  a  longitudinal  slit  in  the  nerve.  It  would  be  better 
to  use  tubes  bent  at  right  angles,  one  arm  being  inserted  into 
the  nerve,  the  other  projecting  out  of  the  wound.  The  tubes 
should  be  of  soft  metal  so  they  can  be  bent  at  any  desired  point  and 
they  should  be  almost  as  large  in  diameter  as  the  nerve,  so  there 
will  be  no  danger  of  being  occluded. 

LATE  TETANUS.— L.  Berard.    Bull,  de  VAcad.  de  med.,  Paris, 
1915,  lxxiv,  p.  234. 

Berard  describes  a  series  of  cases  of  tetanus  coming  on  late 
after  the  original  infection.  They  begin  gradually ;  at  first  there 
are  only  slight  contractures,  which  are  gradually  progressive. 
All  the  classical  symptoms  of  tetanus  are  present,  but  in  mild 
degree  only.  One  sign  which  is  almost  constant  is  permanent 
and  progessive  contracture  of  the  abdominal  muscles.  It  is  gen- 
erally taught  that  cases  which  develop  late  end  in  recovery,  and 
the  ones  that  have  a  sudden  and  stormy  onset  are  fatal.  But 
these  cases  of  which  Berard  speaks  generally  result  in  death 
from  paralysis  of  the  respiratory  muscles  and  asphyxia.  He 
believes  they  are  in  general  due  to  reinfection  caused  by  the 
awakening  of  latent  spore  forms  of  tetanus  through  secondary 
surgical  operations. 

In  order  to  prevent  reinfection  a  third  dose  of  antitoxin  should 
be  given,  in  addition  to  the  two  regular  ones,  before  any  sur- 
gical intervention  is  contemplated.  The  objection  might  be 
made  that  there  was  danger  of  anaphylaxis  from  giving  a  third 
dose  of  the  antitoxin,  and  though  this  objection  would  appear 
to  be  justified  on  theoretical  grounds  Berard  has  never  known 
it  to  occur  in  practice,  and  since  pursuing  this  course  he  has 
had  no  further  difficulty  with  these  cases. 

CLINICAL    AND    THERAPEUTICAL    EXPERIENCE    WITH 

TETANUS.— B.    0.   Pribram.     Berl.  klin.   Wchnschr.,   1915, 
lii,  p.  916. 

Pribram  gives  the  case  histories  of  a  series  of  over  40  cases 
and  comes  to  the  following  conclusions : 


126  ABSTRACTS  OF  WAR  SURGERY 

The  localization  of  the  spasms  is  of  great  importance  in 
prognosis.  In  cases  of  lockjaw,  opisthotonos,  and  spasms  of 
peripheral  muscle  groups  the  prognosis  is  relatively  good,  while 
in  spasm  of  the  glottis  and  diaphragm  it  is  practically  hopeless, 
even  if  no  other  muscles  are  involved.  An  early  symptom  that 
is  a  certain  precursor  of  spasm  of  the  diaphragm  is  epigastric 
pain.  The  old  rule  that  the  severity  of  the  infection  is  propor- 
tional to  the  shortness  of  the  incubation  period  does  not  always 
hold  good.  The  true  incubation  is  to  be  reckoned  from  the  time 
of  the  production  of  toxins  by  the  invading  bacteria,  and  this 
does  not  always  coincide  with  the  moment  of  infection.  The 
localization  of  the  spasms  is  independent  of  the  point  of  injury 
and  also  of  the  intensity  of  the  infection.  The  most  frequent 
complication  of  tetanus  is  confluent  lobular  pneumonia ;  barring 
suffocation  from  spasm  of  the  glottis  and  diaphragm,  it  causes 
the  most  deaths. 

In  many  tetanus  patients  and  in  almost  all  who  die  of  tetanus 
there  are  marked  signs  of  status  lymphaticus,  which  indicates 
that  predisposition  plays  an  important  part  in  the  infection. 
The  best  treatment  of  the  wound  is  the  radical  removal  of  all 
necrotic  tissue  until  fresh  bleeding  tissue  is  reached;  escharotic 
antiseptics  and  the  cautery  do  not  appear  to  be  particularly 
effective.  The  question  of  amputation  should  be  decided  on  the 
usual  surgical  principles.  The  severity  of  the  infection  is  not 
at  "all  parallel  to  the  severity  of  the  wound.  It  is  not  logical 
to  give  prophylactic  treatment  except  in  cases  of  severe  in- 
jury. 

Because  of  the  danger  of  pneumonia  ether  should  never  be 
used.  Antitoxin  should  be  given  in  large  doses ;  daily  injections 
of  200  to  300  units  and  in  addition,  on  the  first  day  an  intradural 
injection  of  400  to  500  units,  with  the  head  lowered.  The  spasms 
can  be  controlled  by  chloral  hydrate,  as  much  as  10  gms.  daily, 
and  the  subcutaneous  injection  of  magnesium  sulphate,  20  c.c. 
of  a  25  per  cent  solution  5  to  6  times  daily.  In  spasms  of  the 
glottis,  efforts  should  be  directed  toward  limiting  normal  re- 
spiratory movements  and  inducing  artificial  respiration.  The 
former  can  be  accomplished  by  bilateral  phrenicotomy  combined 
with  tracheotomy,  intradural  injection  of  magnesium  sulphate, 
and  the  administration  of  large  doses  of  morphine.  If  one  is 
prepared  to  give  artificial  respiration  there  is  no  danger  in 
large  doses  of  morphine.  Artificial  respiration  of  oxygen  is  of 
great  value. 


\BSTRACTS  OF  WAR  SURGERY  127 

INTRANEURAL  INJECTION  OF  TETANUS  ANTITOXIN  IN 
LOCAL  TETANUS.— A.  Meyer.  Berl.  klin.  Wchnschr.,  1915, 
lii,  p.  975. 

It  has  previously  been  demonstrated  experimentally  that  the 
injection  of  antitoxin  into  the  nerve-trunk  of  the  affected  limb 
saves  animals  that  have  been  infected  with  tetanus.  Meyer 
thinks,  however,  that  this  method  of  treatment  has  not  been 
applied  clinically  as  much  as  it  should  be,  and  describes  cases 
in  which  he  feels  confident  that  such  intraneural  injections 
have  saved  the  lives  of  patients.  Many  surgeons  believe  that 
the  prognosis  in  local  tetanus  is  good  even  without  treatment, 
but  he  finds  that  local  tetanus  is  often  only  a  precursor  of  gen- 
eral tetanus,  which  may  be  warded  off  by  intraneural  injection 
before  the  distribution  of  the  toxin  becomes  general. 

STATISTICS  OF  CASES  OF  TETANUS  OBSERVED  IN  THE 
WAR  ZONE  FROM  NOVEMBER  1,  1915,  TO  FEBRUARY 
1,  1917. — P.  Chavasse.  Bull,  et  mem.  Soc.  de  chir.  de  Paris, 
1917,  xliii,  p.  1249. 

The  statistics  of  Chavasse  are  collected  from  the  reports  of 
the  chief  of  the  medical  staff  of  the  French  field  armies  and 
comprise  nearly  all  cases  of  tetanus  occurring  at  the  front  be- 
tween Nov.  1,  1915,  and  February  1,  1917.  The  statistics  do  not 
indicate  cases  occurring  in  the  interior  hospitals,  etc. 

The  eases  are  included  in  three  categories:  (1)  Tetanus  oc- 
curring following  accidental  lesions  or  after  current  surgical 
operation;  (2)  tetanus  occurring  as  a  result  of  frozen  feet 
(trench-foot)  ;  (3)  tetanus  due  to  gunshot  wounds. 

During  the  period  under  consideration  213  cases  were  re- 
ported by  the  armies  at  the  front,  29  being  of  the  first  variety, 
38  of  the  second,  and  146  of  the  third.  Of  the  29  cases  of 
tetanus,  accidental  and  otherwise,  4  had  received  a  prophylactic 
injection — 2  died  and  2  recovered.  Of  25  cases  which  had  re- 
ceived no  preventive  injection,  16  died.  Of  the  38  cases  of 
frozen  foot  tetanus  there  had  been  no  preventive  injection  in 
36  cases.  All  died.  Thirty-two  cases  had  received  from  1  to 
3  injections.     These  cases  gave  29  deaths  and  3  recoveries. 

Of  the  146  gunshot  tetanus  cases  9  had  received  no  injec- 
tions. These  gave  6  deaths  and  3  recoveries.  There  were  137 
postserum  cases  with  107  deaths,  5  of  which  might  be  imputed 
to  other  causes. 


128  ABSTRACTS  OF  WAR  SURGERY 

The  general  conclusions  drawn  by  Chavasse  from  his  detailed 
study  are : 

1.  If  preventive  injections  of  antitetanic  serum,  employed  in 
gunshot  wounds  do  not  always  prevent  the  development  of 
tetanus,  they  have  incontestably  demonstrated  their  efficacy  in 
bringing  about  a  very  notable  diminution  in  this  formidable 
complication.    But  it  can  not  be  held  as  an  unfailing  prophylactic. 

2.  The  gravity  of  tetanus  has  been  shown  to  be  in  accord 
with  the  gravity  of  the  local  lesions.  It  has  been  especially 
prevalent  with  cases  of  frozen  feet.  The  gravity  at  least  in 
war  injuries  appears  to  diminish  according  to  the  number  of 
preventive  injections  even  though  the  wounds  are  very  exten- 
sive. 

3.  The  prophylactic  dosage  has  not  always  been  proportioned 
to  the  gravity  of  the  wounds.  The  usual  dose  of  10  c.c.  ought 
to  be  doubled  or  even  trebled  at  least  for  the  first  injection 
in  the  case  of  very  extensive  wounds  or  dirty  wounds,  especially 
when  foreign  bodies  are  present.  In  wounds  of  medium  grav- 
ity, if  the  first  dose  has  been  one  of  30  c.c,  the  repeated  doses 
should  be  from  10  to  15  c.c,  but  if  the  first  dose  has  been  only 
10  c.c.  then  successive  doses  should  be  stronger,  say  from  20 
to  30  c.c  at  seven  to  eight-day  intervals.  This  will  avoid 
anaphylaxis. 

4.  In  frozen  foot  with  phlyctenular  ulceration  or  sphacela, 
the  first  dose  should  be  20  to  30  c.c,  renewing  with  from  10  to 
15  c.c.  or  even  20  c.c.  in  severe  cases  every  eight  days  till 
recovery. 

5.  In  order  to  fortify  against  late  postoperative  tetanus  it 
is  necessary,  according  to  Berard  and  Lumiere,  to  make  a  pre- 
ventive injection  before  any  surgical  operation  whatever.  The 
dose  should  be  1.0  to  20  c.c.  according  to  the  importance  of  the 
operation. 

LOCAL  TETANUS.— F.  Brunzel.     Berl.  klin.   Wchnschr.,  1916, 
liii,  No.  40. 

Brunzel  reports  the  case  of  a  soldier  who  after  being  wounded 
displayed  symptoms  of  tetanus  which  was  evidently  local,  there 
being  none  or  only  very  slight  general  manifestations.  After 
treatment  by  serum  the  man  appeared  to  be  out  of  all  danger 
when  suddenly  the  temperature  rose  and  within  a  couple  of 
days  he  died  in  delirium  cordis,  fifteen  days  after  the  last  serum 
injection. 


ABSTRACTS    OF    WAR   SURGERY  12ft 

Autopsy  showed  the  heart,  brain,  lungs,  etc.,  quite  normal 
and  the  cause  of  death  was  not  determined.  It  must  be  ad- 
mitted as  very  probable  that  the  death  of  the  patient  was  due 
to  the  tetanus  poison,  notwithstanding  the  large  dosage  of  anti- 
toxin administered.  The  author  thinks  the  case  of  interest  not 
merely  because  it  is  one  in  which  the  tetanic  symptoms  were 
purely  local,  but  more  so  on  account  of  the  delayed  death  which 
occurred  notwithstanding  the  fact  that  the  local  tetanic  symp- 
toms had  disappeared  for  twelve  days  and  that  there  were  no 
general  symptoms  clinically  recognizable. 

It  is  possible  that  in  this  case  there  may  have  been  a  ques- 
tion of  a  particular  variant  of  the  tetanus  bacillus,  the  toxin 
produced  having  a  predilection  for  the  nerve-centers  of  the 
heart  since  the  death  was  a  sudden  cardiac  death. 

The  case  is  of  particular  interest  to  surgeons  because  the 
prognosis  of  a  purely  localized  tetanus  can  not  a  priori  be  said 
to  be  favorable.  The  local  form  is  only  a  special  form  of  the 
general  type  which  is  always  local  at  first.  The  evolution  of 
any  particular  case  can  not  be  foretold  so  that  it  is  best  to  treat 
all  cases  alike  energetically. 

A  REPORT   ON   TWENTY-FIVE    CASES    OF  TETANUS.— H. 

R.  Dean,  Lancet,  London,  1917,  cxcii,  p.  673. 

Dean  reports  a  series  of  twenty-five  cases  of  tetanus  treated 
during  an  interval  of  four  months  at  the  Second  Western  Gen- 
eral Hospital.  The  majority  of  the  men  had  been  wounded  in 
the  battle  of  the  Somme.  Most,  if  not  all,  had  probably  received 
prophylactic  injections  of  antitoxin  in  France.  All  had  sup- 
purating wounds  but,  in  the  majority  of  cases,  they  were  like 
the  average  case  sent  to  a  hospital  in  England.  It  is  significant, 
however,  that  a  compound  fracture  was  present  in  11 ;  in  2  a 
leg  had  been  amputated;  and  in  7  there  was  a  history  of 
foreign  body  in  the  wound.  In  these  cases  there  was  probably 
dead  tissue  present  providing  a  suitable  medium  for  the  growth 
of  the  saprophytic  tetanus  bacillus.  Presence  of  fracture  or 
foreign  body  therefore  constitutes  a  strong  indication  for  pro- 
phylactic antitoxin  injection.  The  length  of  time  elapsing  be- 
tween injury  and  dressing  does  not  seem  to  be  a  factor  in  the 
incidence  of  infection. 

The  incubation  period  in  many  of  these  cases  was  enormously 
increased.  In  10  cases  it  was  over  fifty  days.  In  5  cases  it 
was  about  three  months.     In  9  the  wounds  at  the  time  of  on- 


130  ABSTRACTS  OF  WAR  SURGERY 

set  of  symptoms  were  completely  or  almost  completely  healed. 
In  at  least  5  cases  the  wounds  were  such  that  probably  no  one 
would  have  selected  the  cases  for  prophylactic  treatment.  This 
latency  of  infection  is  due  to  the  prophylactic  infection.  Un- 
less this  fact  is  recognized  incipient  cases  will  be  overlooked 
and  valuable  time  lost  in  instituting  treatment. 

The  earliest  signs  may  be  rheumatic  pain  and  stiffness.  Of 
the  25  cases,  6  received  aspirin  at  the  onset.  Or  the  first 
symptom  may  be  tonic  or  clonic  spasm  of  muscles  in  the  im- 
mediate neighborhood  of  the  wound,  usually  in  the  nearest 
flexor  group.  In  4  of  these  cases  it  remained  so  localized,  in 
10  others  it  finally  became  generalized,  and  in  11  there  was 
sudden  involvement,  first  of  muscles  of  the  jaws  and  neck. 
Some  of  these  had  received  prophylactic  injection. 

Of  5  mild  cases  treated  by  intramuscular  injection,  all  re- 
covered. Of  14  serious  generalized  cases  treated  by  intraven- 
ous injection,  13  recovered.  Of  5  treated  by  intrathecal  injection 
with  or  without  other  injection,  3  recovered. 

The  choice  of  method  of  injection  should  be  governed  by  the 
essential  principle  of  treatment,  which  is  to  neutralize  the  toxin 
at  the  earliest  possible  moment.  This  object  can  be  most  eas- 
ily attained  by  the  intravenous  route.  The  subcutaneous  and 
intramuscular  injections  are  absorbed  but  slowly  and  valuable 
time  is  lost.  As  regards  the  regulation  of  the  size  of  dose  the 
intrathecal  method  is  the  least  advantageous.  In  5  of  the  cases 
injected  intravenously  cerebrospinal  fluid  was  obtained  by  lum- 
bar puncture  and  antitoxin  demonstrated  by  injection  into 
animals.  It  is  obviously  desirable  to  distribute  antitoxin  to 
every  part  of  the  central  nervous  system.  The  arteries  and 
capillaries  afford  ideal  channels  for  such  distribution.  It  is 
difficult  to  believe  that  serum  injected  into  the  lumbar  theca 
reaches  the  cells  in  the  medulla  more  quickly  than  serum  which 
is  injected  into  a  vein. 

From  experimental  study  of  the  blood  serum  of  7  of  the 
patients  it  was  determined  that  from  twenty  to  thirty-nine  days 
after  injection  of  30,000  units  the  blood  of  the  patient  may 
contain  appreciable  quantities  of  antitoxin.  This,  together  with 
clinical  evidence  in  6  of  the  patients  who  received  only  one 
injection  and  who  promptly  recovered,  would  seem  to  indicate 
that  there  is  no  advantage  in  frequent  injections  of  serum. 


ABSTRACTS   OP    WAR   SURG)  i;  ,  131 

THE  INTRATHECAL  ROUTE  FOR  THE  ADMINISTRATION 
OF  TETANUS  ANTITOXIN.— F.  W.  Andrews.  Lancet, 
London,  1917,  cxcii,  p.  682. 

The  relative  merits  of  the  subcutaneous,  intramuscular,  in- 
travenous, and  intrathecal  methods  of  administering  tetanus 
antitoxin  practically  can  not  be  determined  by  the  statistical 
method.  The  primary  object  always  being  to  cure  the  patient, 
more  than  one  route  is  employed,  and  wide  variation  occurs  in 
the  dosage.  The  cases  differ  widely  in  the  severity  of  infec- 
tion and  in  accidental  complications  and  the  more  heroic  method 
of  injection  is  apt  to  be  chosen  in  the  most  desperate  cases. 

Reliable  data  is,  however,  available  from  animal  experimen- 
tation. Permin  of  Denmark,  showed  that  antitoxin  intrathecally 
prevented  tetanus  when  intravenous  injection  did  not.  Park 
and  Nicoll  injected  two  minimal  lethal  doses  of  toxin  into 
guinea  pigs,  waited  until  spasm  of  the  legs  commenced,  and 
then  tried  antitoxin  by  various  routes.  In  experiments  on  18 
guinea  pigs,  2  controls  and  6  treated  by  the  intracardiac  and 
4  by  the  intraneural  routes,  all  died,  while  of  6  receiving  much 
smaller  intrathecal  doses  5  recovered.  Sherrington,  working 
with  monkeys,  found  that  10  control  monkeys  and  those  treated 
subcutaneously  all  died.  Of  12  treated  intramuscularly  all 
died.  Of  16  treated  by  intravenous  injection  10  died,  62.6  per 
cent.  Of  18  treated  by  the  intrathecal  route  5  died,  27.7  per 
cent. 

The  author  reports  20  cases,  16  of  which  were  treated  in- 
trathecally with  2  deaths.  He  believes  there  is  less  danger  of 
anaphylactic  reaction  by  intrathecal  than  by  intravenous  injec- 
tion and  that  the  danger  of  meningeal  infection  with  ordinary 
care  should  be  negligible.  An  insufficiently  treated  case  of 
local  tetanus  tends  to  become  general.  The  intrathecal  rather 
than  the  subcutaneous  route  should  therefore  be  chosen  in  all 
incipient  cases.  Except  in  established  cases  the  intrathecal 
method  seems  safer  in  local  tetanus  also  because  of  the  tendency 
to  become  general. 

A  COMPARISON  OF  SUBCUTANEOUS  WITH  INTRAVEN- 
OUS ADMINISTRATION  OF  TETANUS  ANTITOXIN  IN 
EXPERIMENTAL  TETANUS.— F.  Golla.  Lancet,  London, 
1917,  cxcii,  p.  686. 

Tests  on  rabbits  and  cats  show  an  indubitable  superiority  of 
the  intravenous    and  intrathecal    route  over    the  subcutaneous, 


132  ABSTRACTS  OP  WAR  SURGERY 

possibly  due  to  the  slower  absorption  by  the  latter  route.  The 
whole  problem  of  serum  therapy  seems  to  be  to  cut  off  a  fresh 
supply  of  toxin  by  bringing  antitoxin  into  relation  with  the 
focus  of  infection.  The  toxin  apparently  can  not  be  neutralized 
after  it  has  entered  the  central  nervous  system. 

The  prophylactic  administration  of  serum  has  converted  man 
from  a  susceptible  to  a  resistant  organism,  as  evidenced  by  the 
occurrence  in  the  majority  of  cases  of  local  spasm  of  muscles 
supplied  by  the  spinal  segment  directly  in  nervous  continuity 
with  the  wound — a  clinical  picture  previously  very  rare  in  man 
but  common  in  highly  resistant  animals. 

The  toxin  may  remain  localized  or  may  invade  the  whole  nervous 
system.  It  is  therefore  of  greater  importance  to  use  the  more 
rapid  intravenous  or  intrathecal  methods  in  those  not  having 
received  prophylactic  treatment,  but  the  more  rapid  method  is 
also  the  safer  in  either  group. 

TETANUS  IN  WAR.— Rev.  of  War  Surg,  and  Med.,  July,  1918. 

A  survey  of  the  literature  of  Tetanus  accumulated  during  the 
present  war,  impresses  one  with  the  truth  of  Major  Eobertson's 
(U.  S.  R.)  statement  that  there  is  hardly  any  other  disease  or 
any  other  bacillus  about  which  so  much  is  known,  yet  about  which, 
beyond  the  limits  of  that  knowledge,  so  many  questions  could  be 
raised.  Many  of  the  doubts  and  uncertainties  were  in  a  measure 
clarified  at  the  meeting  of  the  Research  Society  of  the  American 
Red  Cross  in  France  on  January  14  and  15,  1918,  reported  in  the 
Red  Cross  Medical  Bulletin,  No.  4.  At  this  meeting  Colonel  Sir 
William  Leishman,  R.A.M.C,  stated  that  experience  had  taught 
that  the  prophylactic  dose  of  500  units  which  we  in  America 
were  accustomed  to  administer,  was  a  quite  sufficient  dose  for  the 
majority  of  war  wounds,  but  in  instances  of  severe  injury,  where 
the  wounds  are  large,  deep  and  heavily  contaminated,  and 
especially  when  fracture  constitutes  a  wound  complication,  a 
prophylactic  dose  of  1,000  to  1,500  units  is  necessary.  All  medi- 
cal officers  are  now  under  direction  to  administer  this  larger  dose 
in  instances  of  severe  wounds,  and  also  in  those  instances  where 
the  wounded  man  has  lain  out  in  "No  Man's  Land"  for  two  or 
three  days. 

Leishman  also  called  attention  to  the  necessity  of  administering 
tetanus  antitoxin  prophylactically  in  all  cases  of  trench  foot. 
Early  in  the  war,  this  was  done  only  in  those  cases  of  trench  foot 
where  there  was  obvious  blistering  of  the  skin.  Tetanus,  how- 
ever, continued  to  be  such  a  constant  complication  of  trench  foot, 


ABSTRACTS  OF  WAR  SURGERY  133 

that  this  order  was  changed  and  a  prophylactic  injection  was 
given  even  where  there  was  no  obvious  skin  lesion.  Since  this 
last  order  has  gone  into  effect,  tetanus  has  been  practically 
stamped  out  as  a  complication  of  trench  foot. 

The  question  of  repeating  prophylactic  doses  has  been  actively 
discussed  for  two  or  three  years.  Sir  David  Bruce,  of  the  English 
Tetanus  Committee,  has  recommended  that  four  prophylactic  doses 
should  be  given  at  intervals  of  from  seven  to  eight  days.  In 
France  this  recommendation  has  been  adopted,  with  the  reserva- 
tion, however,  that  it  need  not  apply  to  those  soldiers  with  only 
slight  wounds.  This  reservation  was  made  in  order  to  avoid  hold- 
ing men  unnecessarily  long  in  hospitals.  In  the  lesser  injuries, 
only  two  doses  are  given,  but  the  graver  cases  receive  four  pro- 
phylactic injections.  Sometimes  the  third  and  fourth  doses  are 
administered  after  a  soldier  has  been  transported  back  to  Eng- 
land. Statistical  proof  is  lacking  regarding  the  increased  amount 
of  protection  given  by  multiple  doses,  and  on  this  ground  the 
Tetanus  Committee  considered  it  to  be  an  obviously  sound  policy 
to  maintain  the  antitoxin  concentration  in  the  blood  over  the 
period  during  which  danger  might  be  anticipated. 

From  this  point  of  view  of  prophylaxis,  it  is  important  to  re- 
member that  tetanus  spores  may  lie  dormant  quite  a  while,  only 
to  be  stirred  into  activity  at  the  time  of  the  necessary  second 
operation.  The  practical  significance  of  this  fact  is  that  second 
operations  should  always  be  preceded  by  prophylactic  injections. 
"Wounds  involving  injured  bone  or  those  complicated  by  retained 
foreign  bodies,  are  with  particular  frequency  associated  with  the 
late  development  of  tetanus  following  secondary  operation. 

The  question  which  more  than  any  other  is  shrouded  in  doubt 
and  uncertainty  is  the  common  one  regarding  the  method  of 
administration  of  antitoxin.  It  may  be  administered  intraven- 
ously, intrathecally,  intramuscularly,  intraneurally,  and  subcuta- 
neously.  Leishman  stated  as  his  belief  that  we  were  neither  in  a 
position  to  favor  definitely  any  one  of  these  methods,  nor  to  say 
which  was  unqualifiedly  the  best  system  of  dosage.  From  innu- 
merable laboratory  experiments  a  great  deal  is  known  of  the  effects 
of  antitoxin  on  infected  animals,  and  the  rate  of  absorption,  but 
we  can  not  determine  in  the  case  of  the  wounded  soldier  to  what 
degree  either  the  tetanus  toxin  has  penetrated  or  to  what  extent 
the  outpouring  of  fresh  tetanus  toxin  is  still  going  on.  The  dose 
of  the  remedy  is  known,  but  not  the  dose  of  the  poison  against 
which  it  is  administered. 


134  ABSTRACTS  OF  WAR  SURGERY 

The  impressions  gained  in  France  have  led  many  observers 
to  attach  more  value  to  the  intramuscular  and  subcutaneous  chan- 
nels than  to  the  other  three  methods.  The  English  Tetanus  Com- 
mission, however,  were  not  in  accord  with  this,  but  held  rather 
that  repeated  intrathecal  injections  should  hold  the  first  place. 
No  one  seems  to  attach  much  importance  to  the  intraneural  route. 
Figures  and  analyses  appear  to  indicate  that  the  channels  by 
which  the  antitoxin  was  more  slowly  absorbed  (intramuscular, 
subcutaneous)  had  given  better  results  on  the  whole  than  those 
by  which  the  antitoxin  was  more  rapidly  absorbed  (intravenous 
and  intrathecal).  On  the  other  hand,  there  is  a  large  amount 
of  experimental  data  which  would  appear  to  emphasize  the  value 
of  the  intrathecal  method,  especially  if  employed  early.  The 
intravenous  method  seems  not  to  be  in  very  common  use,  a  fact 
which  Leishman  considers  unfortunate,  for  the  reason  that  it  is 
obviously  the  most  rapid  and  thorough  way  by  which  to  saturate 
the  blood  and  tissues  with  antitoxin.  No  case  in  France  treated 
only  by  this  method  has  recovered. 

Robertson  stated  that  experiments  upon  laboratory  animals 
had  shown  that  each  successive  inoculation  lessened  the  period  of 
immunity.  After  the  first  prophylactic  injection,  the  immunity 
period  lasted  approximately  twenty-one  days.  The  second  injec- 
tion, however,  was  as  quickly  eliminated  by  the  body  as  any  other 
foreign  substance,  requiring  only  seven  to  eight  days  as  a  max- 
imum. The  third  dose  was  effective  for  even  a  shorter  period. 
Theoretically,  then,  by  repeating  the  doses,  we  reduce  the  patient's 
ability  to  hold  the  antitoxin  in  the  blood.  This  fact  is  important 
in  pointing  out  the  lesson  that  a  prophylactic  dose  administered 
before  a  second  operation  may  not  afford  protection  over  a  very 
long  time. 

On  the  question  of  doses  in  the  treatment  of  the  disease,  there 
seems  to  be  a  general  agreement  only  on  a  few  points,  namely — 
the  necessity  of  high  dosage ;  the  early  administration  of  treat- 
ment and  the  persistence  in  administration  well  along  into  con- 
valescence. It  must  be  stated,  however,  that  huge  doses  have 
failed  to  save  a  patient,  whereas  in  other  instances,  what  appeared 
to  be  totally  inadequate  doses  were  accompanied  by  recovery. 

Robertson  reported  that  a  careful  examination  of  the  soil  from 
all  parts  of  the  Western  front  showed  that  wherever  it  had  been 
cultivated  it  had  been  infected  to  such  an  extent  that  the  inocula- 
tion in  a  laboratory  animal  of  only  one  grain  invariably  produces 
tetanus.     One  must,  of  course,  always  bear  in  mind  that  the  body 


ABSTRACTS  OF  WAR  SURGERY  135 

as  well  as  the  clothing  of  every  soldier  is  saturated  with  infected 
soil. 

The  general  tendency  of  the  members  of  the  Research  Society, 
as  mirrored  in  remarks  by  both  Major  Blake  and  Colonel  Sir 
William  Leishman,  was  very  distinctly  against  the  use  of  mag- 
nesium sulphate.  That  this  drug  undoubtedly  controlled  convul- 
sions was  not  disputed,  but  it  was  very  far  from  certain  that  it 
did  not  unfavorably  influence  the  course  of  the  disease.  One  of 
the  most  significant  points  brought  out  in  the  discussion  was  that 
we  should  always  bear  in  mind  that  the  tetanus  bacillus  itself 
was  not  the  only  factor  in  the  development  of  symptoms.  We 
must  reckon  in  the  first  place  with  the  resistance  of  the  wounded 
individual,  and  an  even  more  important  consideration  is  the  nature 
and  condition  of  the  wound.  Clean  incised  wounds  are  followed 
by  tetanus  as  a  complication  with  markedly  less  frequency  than 
are  badly  contused  lacerated  wounds. 

Although  The  Medical  Bulletin  report  contains  no  specific  state- 
ment regarding  wound  excision,  one  is  thoroughly  warranted  in 
assuming  that  careful  wound  excision  is  in  itself  a  powerful  factor 
in  combating  tetanus. 

The  discussion  seemed  to  confirm  the  old-fashioned  fact  that 
the  severity  of  the  clinical  symptoms  are  in  inverse  proportion 
to  the  length  of  incubation  period  of  the  disease.  The  shorter 
the  incubation  period,  the  more  severe  the  attack. 

As  to  methods  of  treatment  other  than  the  specific  use  of  anti- 
toxin, Leishman  stated  that  the  two  methods  chiefly  tried  in  the 
earlier  period  of  the  war  were  magnesium  sulphate  and  carbolic 
acid,  both  of  which  have  gradually  fallen  into  disuse.  Both  have 
been  disappointing.  The  use  of  carbolic  acid  seems  to  have  been 
completely  abandoned.  Chloral,  morphine,  and  bromides  were 
relied  upon  and  were  found  to  be  generally  useful,  provided  they 
were  not  administered  in  poisonous  doses. 

In  the  Lancet  for  December  22,  1917,  Sir  David  Bruce  furnishes 
an  extensive  analysis  of  all  the  tetanus  cases  treated  in  the  home 
military  hospital.  This  analysis,  abstracted  in  the  Medical 
Record,  January  26,  1918,  shows  a  decided  decrease  in  the  mor- 
tality rate  (19  per  cent)  over  that  of  the  first  analysis,  which 
gave  a  mortality  of  57.7  per  cent.  He  considers  that  whatever 
the  cause — the  prophylactic  dose  of  serum,  better  surgical  treat- 
ment, quicker  diagnosis,  more  thorough  therapeutic  treatment, 
etc. — the  result  is  gratifying.  In  regard  to  the  proportion  of 
wounded  men  who  contract  tetanus  in  home  hospitals,  the  number 
may  be  roughly  put  down  at  1  per  1,000,  but  since  the  number  of 


136  ABSTRACTS  OF  WAR  SURGERY 

wounded  in  England  has  not  been  published,  it  is  impossible  to 
tell  this  with  exactness.  This  last  analysis  deals  with  100  cases 
and  shows  that  if  the  symptoms  of  tetanus  appeared  within  ten 
days  of  receiving  the  wound  the  mortality  was  40  per  cent;  if 
from  the  eleventh  to  the  twenty-fourth  day,  25  per  cent.  The 
remaining  66  cases,  with  an  incubation  period  of  from  25  to  786 
days,  averaged  a  mortality  of  13.66  per  cent.  This  last  incuba- 
tion period  of  786  days  is  a  doubtful  case,  according  to  Bruce. 
The  man  was  reported  to  have  three  attacks  of  tetanus.  The  last 
attack,  with  such  a  lengthy  incubation  period,  was  probably  due 
to  a  nervous,  hysterical  condition  which  was  mistaken  for  tetanus. 
It  has  been  demonstrated,  however,  that  the  tetanus  bacilli  may 
remain  quiescent  for  long  periods  at  the  site  of  old  wounds,  so 
that  786  days  would  not  seem  to  be  an  impossible  incubation 
period.  The  shortest  period  of  incubation  was  3  days,  the  longest 
239.  There  were  only  10  cases  with  a  short  incubation  period, 
and  69  cases  with  an  incubation  period  of  more  than  22  days. 
Statistics  are  showing  that  the  average  incubation  period  has 
been  steadily  lengthening  since  the  beginning  of  the  war.  Bruce 
attributes  this  change  principally  to  the  prophylactic  injection 
of  antitoxin.  In  the  first  year  of  the  war  there  were  47  per  cent 
of  cases  with  a  short  incubation,  while  the  last  analysis  showed 
a  reduction  to  10  per  cent.  In  1914-15  there  were  only  6.4  per 
cent  of  cases  with  a  long  incubation  period;  this  has  risen  to  69 
per  cent.  During  the  first  year  of  the  war  many  of  the  wounded 
did  not  receive  the  prophylactic  dose  of  antitoxin,  hence  the  num- 
ber of  acute  cases  with  a  short  incubation  period.  Of  the  100  cases 
under  consideration  in  this  last  analysis,  81  were  classed  as  cases 
of  general  tetanus  and  19  as  cases  of  local  type.  In  the  81  cases 
of  generalized  tetanus  there  were  58  recoveries  and  25  deaths,  a 
mortality  of  28.3  per  cent.  All  the  cases  of  localized  tetanus 
recovered.  There  were  6  cases  in  which  tetanus  followed  on  an 
operation  with  one  death.  In  none  of  these  cases  was  a  prophy- 
lactic inoculation  of  antitetanic  serum  given  before  the  operation. 
As  a  result  the  Tetanus  Committee  advises  that  when  operations 
are  performed  at  the  site  of  wounds,  even  if  they  are  healed,  the 
prophylactic  injection  of  serum  should  invariably  be  given. 
Among  the  100  cases,  73  received  a  prophylactic  injection  of  serum 
in  France.  Twenty-one  cases  received  secondary  prophylactic 
injection;  8  received  three  injections,  4  received  four  injections, 
and  1  received  five  injections.  Of  the  73,  60  recovered  and  13 
died,  a  mortality  of  17.7  per  cent.     Of  the  remaining  27  cases, 


ABSTRACTS  OP  WAR  SURGERY  137 

13  gave  no  history  of  prophylactic  treatment,  11  of  which  recov- 
ered and  2  died.  The  remaining  14  cases  gave  no  history  of 
prophylactic  injection  of  any  kind;  of  these  10  recovered  and  4 
died.  In  the  100  cases  reviewed  the  mortality  was  19  per  cent. 
While  but  78  of  these  cases  were  reported  as  having  received  a 
prophylactic  injection  in  France,  the  whole  of  them  were  treated 
with  antitetanic  serum.  Eighty-one  recovered,  19  died,  giving  a 
mortality  of  19  per  cent.  The  various  routes  of  injection  of  the 
antitetanic  serum  were  employed  with  no  definite  results  as  to 
the  advantage  of  any  special  route,  nor  was  the  influence  of  the 
amount  of  dosage  brought  to  any  definite  conclusion.  Bruce  sums 
up  the  results  of  his  fifth  analysis  as  follows :  ( 1 )  In  the  100 
cases  of  tetanus  under  review  the  mortality  was  only  19  per  cent. 
(2)  The  incubation  period  tends  to  become  longer,  due  to  the 
prophylactic  injection.  Hence  there  are  only  10  cases  reported 
with  an  incubation  of  10  days  or  under.  (3)  Only  14  cases  are 
reported  to  have  received  secondary  prophylactic  injections  of 
antitetanic  serum  in  home  hospitals.  (4)  In  regard  to  the  thera- 
peutic effect  of  antitoxic  serum,  the  evidence  is  still  inconclusive. 


GAS  GANGRENE 

GAS  GANGRENE.— (ANAEROBIC,  ACUTE  BACILLARY,  OR 
WAR  GANGRENE.— Rev.  of  War  Surg,  and  Med.,  March, 
1918,  i,  No.  1. 

In  facing  the  problem  of  gas  gangrene,  three  fundamentally 
significant  considerations  must  be  borne  in  mind  if  one  hopes 
to  gain  an  orderly  conception  of  this  vitally  important  subject 
of  war  surgery : 

1.  Bacteriologically  there  is  some  doubt  as  to  whether  we 
have  to  deal  always  with  the  same  strain  of  gas-producing  bac- 
teria. This  point  has  an  important  bearing  on  the  problem  of 
developing  a  specific  antiserum.  Of  even  more  significance 
than  this  is  the  fact  that  gas-producing  organisms  almost  al- 
ways occur  in  common  with  other  bacteria   (symbiosis). 

2.  Clinically  the  cases  vary  along  general  lines,  depending 
upon  the  predominance  of  symptoms  referable  to  the  presence 
of  gas,  the  development  of  edema,  and  the  tendency  to  gan- 
grene. 

3.  Anatomically  variations  occur,  depending  upon  whether 
the  process  is  superficial  (subcutaneous)  or  deep  (intramuscu- 
lar). (Taylor  contends  that  subcutaneous  gas  is  always  es- 
caped intramuscular  gas). 

One  of  the  most  important  contributions  to  the  bacteriology 
of  gas  gangrene  was  made  by  Bull  and  Pritchett  of  the  Rocke- 
feller Institute,  who  experimented  with  five  strains  of  Bacillus 
welchii,  four  from  infected  wounds  in  the  western  theater  of 
war,  and  one  obtained  from  a  personal  article  of  clothing.  Tests 
for  motility,  spore  formation,  quantitative  acid  and  gas  pro- 
duction, liquefying  action  on  gelatin  at  22  and  37  C,  patho- 
genicity for  guinea  pigs,  rabbits,  and  pigeons,  and  for  still 
other  properties,  place  all  five  cultures  among  the  group  of  B. 
welchii;  so  far  as  they  relate  to  specific  properties,  e.  g.,  spe- 
cific and  cross  agglutination,  they  indicate  certain  differences 
among  them  such  as  have  been  commonly  observed  among  mem- 
bers of  the  group. 

Considering  the  cause  of  death  in  B.  welchii  infection,  Bull 
and  Pritchett  state  that  in  man  infection  with  this  organism 
tends  to  be  a  local  process,  even  when  severe,  and  invasion  of 

138    . 


ABSTRACTS  OF  WAR  SURGERY  139 

the  general  blood  occurs,  if  at  all,  only  during  the  death  agony 
or  postmortem.  In  a  small  number  of  cases  in  man  general 
infection  seems  to  have  played  an  important  part  in  causing 
or  hastening  death.  But  as  these  cases  are  the  exception,  even 
when  death  occurs,  in  man  as  well  as  in  the  pigeon,  rabbit,  and 
guinea  pig,  it  may  be  assumed  that  soluble  chemical  substances 
entering  the  circulation  from  the  local  lesion  bring  about  the 
severe  symptoms  and  the  fatal  termination. 

From  further  experiments  upon  rabbits,  the  purpose  of  which 
was  to  discover,  if  possible,  soluble  toxic  substances  in  the  fluid 
cultures,  it  was  found  that  an  acutely  fatal  effect  can  be  pro- 
duced from  large  quantities  of  a  broth  culture  injected  in- 
travenously. From  the  experiments  thus  far,  it  would  appear 
that  the  acutely  fatal  effects  of  massive  doses  of  the  broth  cul- 
tures as  such  or  when  separated  in  large  part  from  the  bacilli 
themselves  are  due  to  some  body  causing  rapid  and  extensive 
blood  destruction.  Acidity  was  ruled  out,  by  further  experi- 
ments, as  the  main  factor  in  causing  either  blood  destruction 
or  the  fatal  effects.  It  was  also  found  that,  in  the  test  tube  at 
least,  the  B.  welchii  produces  an  active  hemolysis. 

Experiments,  several  times  repeated  and  always  consistent, 
showed  that  intravenous  injections  of  broth  cultures  are  at- 
tended by  extensive  blood  destruction  and  death ;  intramuscu- 
lar injections  of  like  doses  cause  death  with  equal  certainty 
and  rapidity,  but  no  blood  destruction.  The  essential  toxic 
agent,  then,  appears  to  be  not  an  acid  and  not  an  hemolysin. 

Experiments  with  the  toxic  filtrate  show  that  B.  welchii, 
when  the  conditions  of  growth  are  suitable,  yields  toxic  prod- 
ucts of  high  potency.  These  products  produce  two  sets  of  ef- 
fects, according  to  the  manner  of  their  injection  into  animals : 
(a)  Hemolysis,  in  which  they  resemble  the  effects  arising  from 
ordinary  glucose  broth  cultures;  (b)  inflammation  and  necrosis 
of  subcutaneous  tissue  and  muscles,  in  which  they  resemble  the 
effects  produced  by  the  bacilli  themselves.  Even  moderate 
quantities  of  the  toxic  filtrate  locally  injected  may  also  bring 
about  rapid  death  of  pigeons. 

The  cause  of  death,  then,  in  B.  welchii  infection  is  not  a 
blood  invasion  of  the  microorganisms  and  not  acid  intoxication, 
but  an  intoxication  with  definite  and  very  potent  poisons  pro- 
duced in  the  growth  of  the  bacilli  in  the  tissues  of  the  body. 
The  authors  call  attention  to  the  fact  that  this  conception  of 
the  manner  of  pathogenic  action  of  the  Welch  bacilli  is  totally 
different  from  any  view  previously  held. 


140  ABSTRACTS  OF  WAR  SURGERY 

Kenneth  Taylor,  the  pathologist  of  the  American  Ambulance 
in  Neuilly,  considers  as  possible  factors  responsible  for  the  gan- 
grene: (1)  The  endotoxin  contained  in  the  bacillus;  (2)  the 
exotoxin  elaborated  by  the  bacillus;  (3)  the  toxin  elaborated 
from  the  tissue  undergoing,  or  which  has  undergone,  degenera- 
tive changes  due  to  the  action  of  the  bacillus  (this  agent  the 
author  terms  "tissue  toxin")  ;  and  (4)  the  gas  produced  by 
the  bacillus.  No  endotoxin  of  appreciable  activity  is  present 
in  B.  aerogenes  capsulatus,  the  exotoxin  is  an  important  part 
of  the  infection,  the  tissue  toxin  is  perhaps  a  more  active  fac- 
tor in  the  intoxication  than  is  the  toxin  formed  by  the  bacilli, 
and  the  presence  of  gas  is  important  from  (1)  its  toxicity,  and 
(2)  its  mechanical  action. 

Taylor  experimented  extensively  in  his  study  of  the  role 
played  by  gas  and  determined  that  the  actively  growing  bacilli 
are  capable  of  producing  a  pressure  which  must  be  extremely 
destructive  to  living  tissue,  and,  further,  that  this  pressure 
must  be  generated  within  a  very  short  period  of  time  if  the 
process  is,  as  frequently  occurs,  restrained  by  a  firm  muscle 
sheath.  This  pressure  must,  of  course,  produce  a  complete 
anemia  of  the  muscle  within  which  the  pressure  is  generated 
and  maintain  this  anemia  until  the  rupture  of  the  muscle  sheath 
occurs. 

The  author  concludes  further  that  the  subcutaneous  crepita- 
tion, which  is  so  often  a  symptom,  is  probably  produced  by  gas 
which  has  forced  itself  through  the  muscle  sheaths,  and  not 
by  gas  produced  by  the  bacillus  in  this  tissue,  where,  indeed, 
it  is  rarely  to  be  found.  He  believes  that  when  such  passage 
is  occluded,  the  explosive  type  of  the  infection  may  be  the  re- 
sult. He  thinks  it  also  probable  that  the  bacteria  are  scattered 
by  the  gas  pressure,  especially  when  it  causes  the  rupture  of 
restraining  tissues. 

Taylor  calls  attention  to  the  new  surgical  problem  involved 
in  the  effective  drainage  of  the  gas  instead  of  a  purulent  ma- 
terial. The  bulging  of  the  muscle  often  closes  the  surgical  in- 
cisions. Incisions  parallel  to  the  muscles  are  inadequate. 
Transverse  section  is  impracticable.  The  author  believes  that 
the  success  of  many  amputations  in  serious  cases  is  in  part  due 
to  the  opportunity  for  effective  drainage  made  possible  by  the 
transverse  section. 

The  author  further  concludes : 

1.  The  gas  produced  by  the  B.  aerogenes  capsulatus  is  of 
little  or  no  importance  as  a  toxic  factor. 


ABSTRACTS  OP  WAR  SURGERY  141 

2.  The  mechanical  action  of  the  pressure  produced  is  usually, 
if  not  always,  the  most  important  part  of  the  infection.  To 
it  may  be  charged  the  development  of  highly  pathogenic  pos- 
sibilities in  a  usually  rather  innocent  infection.  It  brings  about 
(a)  the  death  of  the  tissues  from  the  resulting  anemia  pro- 
duced by  a  pressure  much  higher  than  that  of  the  circulating 
blood;  (b)  the  actual  mechanical  fragmentation  of  the  tissues, 
especially  muscle;  and  (c)  the  mechanical  scattering  of  the  in- 
fection. 

3.  One  of  the  chief  problems  in  the  treatment  of  the  infec- 
tion is  that  of  establishing  drainage  for  the  escape  of  the  gas 
before  the  pressure  has  resulted  in  the  death  of  the  tissue. 

Taylor's  emphasis  of  the  importance  of  the  mechanical  fac- 
tor is  supported  by  Heitz-Boyer,  who,  in  a  paper  on  "Hema- 
toma and  Gaseous  Gangrene,"  calls  attention  to  the  relationship 
that  may  exist  between  a  localized  hematoma  and  gaseous  gan- 
grene in  the  region  just  below  it.  Some  such  hematomas  caused 
by  lesions  of  the  large  blood  vessels  serve  to  check  a  serious 
hemorrhage,  but  in  so  doing  they  may  lead  to  gaseous  gangrene. 
Thus  a  kind  of  secondary  gaseous  gangrene  is  almost  inevitable 
in  the  case  of  soldiers  whose  clothing  and  skin  present  a  rich 
and  varied  bacterial  flora. 

After  referring  to  Sacquepee's  bacteriological  study  of  such 
phenomena,  Heitz-Boyer  concludes  that  only  amputation  can 
save  a  case  in  which  this  form  of  gaseous  gangrene  has  set  in; 
but  he  insists  that  by  proper  preventive  treatment  it  may  be 
avoided.  In  every  wound  involving  lesions  of  the  great  blood 
vessels,  he  would  have  the  surgeon  hunt  out  carefully  all  hema- 
tomas, open  them,  and  ligature  the  bleeding  vessel. 

The  mixed  bacterial  flora  usually  associated  with  gas  gangrene 
were  studied  by  Ivens,  who  found,  in  107  cases  studied,  that 
there  was  usually  a  mixed  bacterial  flora:  B.  perfringens  (aero- 
genes  capsulatus)  was  present  in  nearly  every  case,  B. 
sporogenes  in  41  cases,  Vibron  septique  in  6  cases  (several 
fatal),  B.  histolyticus,  B.  Hibler  IX,  and  B.  edematiens  were 
all  reported,  but  less  frequently.  Streptococci  of  a  virulent 
type  were  present  in  59  cases,  and  added  to  the  gravity  of  the 
infection.  Tetanus  occurred  in  15  cases  and  was  demonstrated 
bacteriologically  in  7. 

Eecent  studies  by  Dalyell  attach  much  significance  to  the 
B.  edematiens  as  a  factor  in  gas  gangrene.  The  method  of  cul- 
tivating this  organism  is  described  by  him  as  follows : 

The  test  tube   containing  fluid  medium  is  inoculated  and  is 


142  ABSTRACTS  OF  WAR  SURGERY 

then  heated  above  the  level  of  the  fluid  and  drawn  out  into 
a  thin  neck.  The  mouth  of  the  tube  is  unaltered,  and  the  cot- 
ton-wool plug  is  pushed  down  toward  the  constriction  and  the 
tube  attached  to  a  pump  and  exhausted.  During  the  process 
of  exhaustion  gentle  heating  of  the  fluid  drives  out  all  air  dis- 
solved in  the  liquid,  and  the  tube  is  then  sealed  by  Bunsen 
flame  at  the  constricted  neck  and  is  ready  for  incubation. 

The  author  adds  that  B.  dematiens  is  associated  with  a  pecu- 
liarly severe  form  of  gas  gangrene,  characterized  by  an  acute 
general  intoxication  and  extensive  spreading  solid  edema,  with 
little  gas  formation  other  than  that  due  to  associated  organ- 
isms in  the  neighborhood  of  the  wound.  He  believes  that  a 
more  careful  search  under  anaerobic  conditions  would  reveal 
its  presence  in  many  cases  of  gas  gangrene. 

Two  important  papers  by  Douglas,  Fleming,  and  Colebrook 
and  Weinberg  and  Seguin  deal  with  the  important  aspect  of 
symbiosis.  Douglas,  Fleming  and  Colebrook  recall  the  im- 
portance of  bacterial  symbiosis  which  has  for  many  years  been 
well  established,  especially  in  the  association  of  anaerobes  and 
aerobes,  and  of  B.  influenza  with  staphylococcus  or  A.  xerosis. 

In  the  wounds  of  the  present  war,  bacterial  flora  is  varied. 
The  primary  infection  is  usually  fecal.  In  the  early  stages  of 
a  wound  the  anaerobic  organisms,  B.  perfringens,  (aerogenes 
capsulatus)  and  organisms  of  putrefaction,  flourish  together 
with  streptococci,  B.  proteus,  and  diphtheroids.  The  anaerobes 
gradually  disappear,  and  finally  only  streptococci,  staphylococci, 
diphtheroids,  and,   occasionally,  B.  proteus  remain. 

Besides  the  B.  tetanus,  the  organisms  causing  the  worst  in- 
fections in  the  early  stages  of  a  wound  are  B.  perfringens,  pos- 
sibly B.  edematis  maligni  and  streptococci,  while  in  the  later 
stages  streptococci  are  responsible  for  almost  all  the  serious 
complications.  Although  the  others  do  not  produce  such  com- 
plications, their  presence  in  the  wound  may  be  of  very  great 
importance  if  it  can  be  shown  that  they  in  any  way  stimulate 
the  action  of  the  more  dangerous  varieties.  The  experiments 
are  reported  in  the  paper  to  show  that  this  is  probably  the 
case. 

In  milk  it  was  found  that  the  broth  culture  of  B.  perfringens 
would  grow  only  when  transferred  in  the  dilutions  of  1:10  or 
1 :100.  When,  however,  it  was  combined  with  staphylococcus 
and  streptococcus  it  flourished  in  sowings  up  to  1 :1,000,000. 
When  thus  combined  B.  perfringens  (aerogenes  capsulatus)  de- 
veloped gas  much  more  rapidly  than  under  any  other  conditions ; 


ABSTRACTS   OF    WAR   SURG]  R  i  1  t3 

it  showed  first  in  two  and  one-half  hours,  and  within  lour  hours 
the  gas  equaled  the  bulk  of  the  culture  fluid. 

Further  experiments  with  varying  technic  showed  an  im- 
mensely increased  activity  of  B.  perfringens  when  grown  in 
symbiosis  with  staphylococci  or  streptococci,  and  that  this  in- 
crease of  activity  remained  the  same  when  the  serum  media 
were  neutralized  either  with  respect  to  their  alkalinity  or  to 
their  antitryptic  power. 

It  was  ascertained  also  that  streptococci  and  staphylococci 
are  greatly  stimulated  in  growth  by  the  presence  of  B.  per- 
fringens, and  that  streptococci  are  stimulated  by  the  presence 
of  diphtheroids,  although  diphtheroids  appear  themselves  to  be 
retarded  in  growth  by  the  presence  of  the  streptococci. 

The  authors  believe  that  symbiosis  may  be  responsible  for  some 
of  the  phenomena  of  gas  gangrene  generally  considered  baffling, 
such  as  terrible  infections  from  only  a  few  bacilli,  the  onset  of 
gas  gangrene  after  careful  surgical  cleansing  and  the  "explosive" 
character  of  gas  production  within  a  few  hours. 

Weinberg  and  Seguin  give  a  summary  of  the  results  thus  far 
obtained  from  their  study  of  gaseous  gangrene  since  1914. 

The  Bacterial  Flora  of  Gaseous  Gangrene. — The  authors  have 
studied  91  cases ;  all  but  2  were  military.  They  were  from  all 
parts  of  the  front. 

No  cases  were  caused  by  aerobes  alone.  In  24  cases  the  anaerobes 
were  unaccompanied  by  aerobes;  in  67  they  were  found  in  sym- 
biosis with  one  or  more  aerobe.  In  37  cases  there  was  but  a  single 
anaerobe;    in  54  there  were  more  than  1. 

According  to  their  frequency,  the  anaerobes  take  precedence  as 
follows:  B.  perfringens  (aerogenes  capsulatus)  in  70  cases  (77 
per  cent),  B.  edematiens  in  31  cases  (34  per  cent),  B.  sporogenes 
in  25  cases  (27  per  cent),  B.  fallax  in  15  cases  (16.5  per  cent), 
Vibrion  septique  in  12  cases  (13  per  cent),  B.  tetani  in  9  cases  (10 
per  cent),  B.  histolyticus  in  8  cases  (9  per  cent),  B.  aerofsetidus  in 
5  cases  (5.5  per  cent),  B.  putrificus  in  2  cases  (2  per  cent),  B. 
bifermentans  in  2  cases  (2  per  cent),  B.  Ghon-Sachs  II  in  1  case 
(1  per  cent),  and  B.  tertius  in  1  case  (1  per  cent). 

The  authors  call  attention  especially  to  the  frequency  of  four 
organisms,  two  of  which,  B.  perfringens  and  B.  sporogenes,  were 
already  known  at  the  beginning  of  the  war,  and  the  other  two 
of  which,  B.  edematiens  and  B.  fallax,  have  been  discovered  by 
the  authors  during  the  study  here  outlined. 

All  writers  now  agree  that  B.  perfringens  is  the  organism  most 


144  ABSTRACTS  OF  WAR  SURGERY 

commonly  associated  with  the  infection.  The  importance  of  B. 
edematiens  (found  in  a  little  more  than  one-third  of  the  cases)  lies 
rather  in  the  fact  of  the  seriousness  of  most  of  the  cases  in  which 
it  is  concerned.  Of  the  aerobes  present,  streptococci  appeared  in 
about  40  per  cent  of  the  cases;  it  seriously  affected  the  prognosis. 
Diploccocci  (enterococci)  appeared  in  33  per  cent  of  the  cases. 
Staphylococci  were  somewhat  less  frequent. 

Emery  believes  that  B.  aerogenes  capsulatus  is  the  sole  organ- 
ism responsible  for  gas  gangrene,  and  explains  the  excessive  viru- 
lence of  this  ordinarily  less  virulent  organism  on  the  ground  that, 
for  some  reason,  the  characteristic  power  of  the  leucocytes  has  been 
lessened. 

Taylor,  in  an  article  in  which  he  traces  the  effect  of  the  B. 
aerogenes  from  its  earliest  entry  into  the  body,  agrees  with  Emery 
as  regards  the  sole  agency  of  capsulatus  aerogenes,  but  disagrees 
with  him  in  that  he  thinks  the  mechanical  presence  of  the  gas  is 
the  main  agent  in  producing  gangrene.  The  first  stage  of  gas  in- 
fection Taylor  describes  as  "dormant."  This  condition  is  present 
in  the  majority  of  wounds.  The  organism  has  been  found  present 
in  70  per  cent  of  all  wounds  examined  bacteriologically  at  a  general 
military  hospital.  The  bacteria  are  to  be  found  in  the  dead  mus- 
cle and  gas  is  sometimes  evident  in  the  depths  of  the  wound. 

The  second  stage,  that  of  "gaseous  distension,"  is  marked  by 
a  gaseous  infiltration  of  healthy  tissue.  Retention  of  the  gas  causes 
sustained  pressure.  The  rapid  increase  of  this  intramuscular  pres- 
sure may  quickly  deprive  the  tissues  of  blood  until  they  appear 
to  be  wrung  dry  of  fluids.  At  this  point  the  condition  of  gangrene 
supervenes. 

The  "explosive  stage"  may  then  follow,  in  which  there  is  rapid 
progress  of  the  infection  due  to  the  invasion  of  the  gangrenous 
muscle  by  the  bacilli. 

The  "stage  of  systemic  toxemia"  may  accompany  or  follow  rap- 
idly upon  the  preceding  one.  Collapse  and  death  usually  result. 
Occasionally  a  stage  of  terminal  bacteriemia  is  reached. 

Evidently  the  conditions  which  determine  the  extension  of  the 
process  from  stage  1  to  stage  2  are  the  most  important  from  a 
therapeutic  point  of  view.  After  gaseous  distension  has  developed 
the  problem  becomes  much  more  complicated.  The  author  reviews 
the  various  explanations  of  this  change: 

1.  It  is  contended  that  several  different  organisms  may  pro- 
duce the  disease.  Taylor  believes,  on  the  other  hand,  that  there  is 
but  one  distinct  species — B.  aerogenes  capsulatus — responsible  for 


ABSTRACTS  OF  WAR  SURGERY  145 

nearly  all  cases  of  gas  gangrene.  B.  edematis  maligni  is  the  only- 
other  gas-producing  organism  that  may  cause  extensive  lesions  in 
the  muscles,  but  this  bacillus  rarely,  if  ever,  gives  rise  to  extensive 
gaseous  phlegmons.  It  is,  however,  frequently  found  in  the  wound 
itself.  The  frequent  occurrence  of  subcutaneous  edema,  the  author 
believes,  is  due  to  the  obstruction  of  the  deep  lymphatics  and  veins 
by  intramuscular  pressure  and  not  to  this  organism. 

2.  Taylor  does  not  believe  that  the  different  forms  of  the  disease 
are  due  to  variations  in  the  virulence  of  the  organism,  because  the 
various  strains  of  B.  aerogenes  capsulatus  appear  almost  equally 
virulent  for  animals,  even  when  taken  from  human  cases  of  varying 
severity. 

3.  Taylor  does  not  believe  that  the  invasion  of  the  blood  by  the 
organism  can  be  responsible  for  the  malignant  type  of  the  disease, 
because  the  bacillus  is  rarely  to  be  found  in  the  blood  before  death. 

4.  As  to  the  theory  that  the  absorption  of  soluble  toxic  products 
of  the  bacteria  breaks  down  the  natural  immunity  of  the  patient, 
Taylor  contends  that  the  exotoxin  from  the  organism  is  of  only 
small  toxicity.  Symptoms  of  toxicity  from  a  local  limited  focus 
are  slight. 

5.  Against  the  theory  that  the  progress  of  the  disease  is  due 
to  the  failure  of  active  immunity,  Taylor  contends  that  the  spread 
of  the  infection  is  too  rapid  to  allow  time  for  the  production  of 
antibodies. 

6.  The  spread  of  the  infection  is  frequently  charged  to  injury 
and  thrombosis  of  important  blood  vessels.  Taylor  has  found 
thrombosis  in  autopsy  in  only  a  few  cases  (3  out  of  19),  and  be- 
lieves it  to  have  been  the  result  rather  than  the  cause  of  gaseous 
distention.  Ligature  of  the  main  artery  to  a  limb,  however,  may 
produce  the  death  of  tissues  in  much  the  same  way  as  gaseous 
distention. 

7.  Taylor  has  shown  that  the  gas  itself  is  not  toxic. 

8.  To  the  contention  that  symbiosis  of  the  gas  bacillus  with  other 
organisms  is  responsible  for  a  malignant  infection,  Taylor  replies 
that  there  is  no  constant  similarity  between  the  flora  of  the  various 
cases  of  gas  gangrene. 

Mullaly  and  McNee  and  Hartley  furnish  rather  striking  clinical 
evidence  to  prove  that  in  gas  gangrene  we  are  dealing  not  only  with 
a  toxemia  but  also  with  an  actual  bacteremia. 

Laying  aside  for  a  moment  the  purely  bacteriological  aspect  of 
the  problem  and  considering  only  the  pathological  phenomena  of 
the  spread  of  the  gangrene,  we  learn  from  McNee  and  Dunn  that 


146  ABSTRACTS  OF  WAR  SURGERY 

they  have  never  seen  gas  gangrene  commence  where  injury  to  mus- 
cle could  be  excluded.  Even  in  cases  of  metastatic  gas  gangrene, 
local  muscular  damage  seems  to  be  the  causing  agent.  No  case 
of  gas  gangrene  beginning  in,  and  remaining  localized  to,  sub- 
cutaneous tissue  has  been  noted. 

The  rapidity  of  the  spread  of  gas  gangrene  appears  to  be  its 
most  astonishing  characteristic.  They  have  found  the  condition 
established  within  3y2  hours  after  a  wound,  and  they  have  known 
of  a  fatal  issue  within  12  hours  after  a  thigh  wound.  They  note 
especially  that  rapid  fatality  often  results  from  small  wounds 
with  a  comparatively  small  gangrenous  bulk  of  muscle,  and  they 
conclude  that  "the  material  elaborated  by  the  bacilli,  whether  it 
be  a  true  toxin  or  not,  is  at  any  rate  a  powerful  systemic  poison." 

The  authors  summarize  the  outstanding  facts  derived  from 
their  own  observations  and  those  of  others,  noting  that  gas  gangrene 
tends  to  spread  longitudinally  from  end  to  end  of  a  single  muscle 
while  neighboring  muscles  remain  intact,  also  that  the  anaerobic 
organisms  are  often  to  be  found  in  perfectly  healthy  tissues  at  a 
considerable  distance  from  the  seat  of  infection,  and  when  so  sit- 
uated they  appear  to  produce  no  serious  results.  Although  many 
organisms  are  frequently  to  be  found  in  the  flora  of  gas  gangrene, 
B.  aerogenes  capsulatus  appears  to  the  authors  to  be  the  commonest. 

The  authors  conclude  that  the  rapid  spread  of  gas  gangrene  is 
due  to  the  peculiarities  of  muscle  structure,  the  sheaths  of  muscle 
"being  so  easily  detachable  as  to  form  potential  spaces  into  which 
toxic  material  can  readily  pass,  causing  necrosis  of  the  fibers." 

Bashford  summarizes  his  studies  of  the  pathology  of  gas  gangrene 
as  follows : 

"The  combinations  in  which  'anaerobic'  bacilli  occur  in  gunshot 
injuries  are  exceedingly  virulent.  While  the  bacilli  themselves 
multiply  mainly  in  the  areolar  tissue  of  the  endomysium,  their 
products  actively  destroy  the  endothelium  of  vessels,  muscle  fibers, 
and  blood.  Destruction  of  capillaries,  veins,  and  lymphatics  is 
the  outstanding  feature  of  the  rapid  spread  of  the  infection,  which 
is  also  accompanied  by  swelling  and  degeneration  of  muscle  fibers, 
and  later  by  the  formation  of  gas.  Constitutional  symptoms  aris- 
ing from  interference  with  the  cardiovascular  and  heat-regulating 
mechanism  ultimately  supervene  and  usher  in  the  end." 

He  believes  that  this  theory  helps  to  reconcile  the  contradic- 
tions noted  by  Wallace  between  the  D'Este  Emery  and  Taylor 
theories,  while  it  agrees  with  Wallace 's  clinical  account.  The  author 
however,  adds : 


ABSTRACTS  OP  WAR  SURGERY  147 

"The  production  of  gas  is  a  late  and  really  a  subsidiary  phe- 
nomenon, which  attracts  attention  from  its  mere  peculiarity.  I 
have  not  found  it  plays  any  part  in  the  advance  of  the  infection, 
although  it  contributes  to  the  later  swollen  condition.  It  arises  in 
tissues  long  dead;  for  this  reason  the  term  'gas  gangrene'  is  un- 
fortunate, owing  to  its  implying  the  necessity  of  awaiting  the  de- 
tection of  gas  before  making  a  diagnosis." 

Clinical  Considerations. — Clinically  gas  gangrene  presents  itself 
as  a  fairly  definite  entity,  and  yet,  as  the  work  of  Sacquepee14 
reported  by  Quenu,  shows  there  are  some  moot  points  also  in 
this  chapter.  Sacquepee  encountered  what  he  considered  to  be  a 
special  type  of  gangrene. 

The  form  of  gaseous  gangrene  described  in  this  article  is  what 
Saquepee  terms  "malignant  gaseous  edema."  The  clinical  char- 
acteristics are :  A  considerable  edema  of  the  limb,  generally  more 
marked  at  the  extremity  than  near  the  body ;  a  bronze  discoloration 
at  one  point  but  paleness  elsewhere ;  an  abrupt  demarcation  of  the 
swelling  as  in  erysipelas.  The  neighboring  muscles  as  well  as  the 
subcutaneous  tissues  are  infiltrated.  The  discharge  from  an  incis- 
ion in  the  skin  near  the  wound  appears  brown,  but  slightly  yellowish 
or  colorless  from  an  incision  at  a  little  distance.  An  emphysema  of 
a  much  less  extent  appears  at  the  same  time,  and  is  sometimes  im- 
perceptible clinically,  affecting  only  those  tissues  in  the  vicinity  of 
the  wound.  Incisions  show  no  gas  to  be  present  in  the  region  of 
the  edema.  For  this  reason  Sacquepee  considers  the  edema  the  prin- 
cipal symptom,  and  the  emphysema  of  secondary  importance.  He 
notes  the  peculiar  odor  of  purification  that  escapes  from  the  lesions 
and  the  infrequent  appearance  of  blebs  on  the  skin.  The  general 
condition  is  characterized  by  dyspnea  without  any  considerable 
pulmonary  lesions,  cooling  of  the  body,  weak,  high  pulse,  and  a  pale, 
thin,  yellowish  complexion.    The  mind  remains  clear. 

In  a  few  hours  the  gaseous  edema  develops,  and  when  left  to  it- 
self, invariably  proves  fatal.  It  may  continue  for  12  hours  or  up 
to  4  days.  The  general  and  local  phenomena  do  not  correspond 
necessarily  in  their  development,  for,  although  the  general  phenom- 
ena appear  together  with  local  ones,  they  may  become  acute,  even 
resulting  in  death,  while  the  local  phenomena  remain  limited, 
rarely  involving  the  whole  of  a  single  member. 

From  a  careful  anatomical  study  Sacquepee  concludes  that  at  the 
start  the  lesion  is  entirely  muscular.  There  is  usually  found  at  a 
definite  point  in  the  muscular  mass  near  the  wound,  although  not 
necessarily  contiguous,  a  gangrenous  center,  sometimes  the  size  of  a 


148  ABSTRACTS  OF  WAR  SURGERY 

fist,  appearing  as  a  homogeneous  necrosed  mass  easily  crushed ;  at  a 
less  advanced  stage,  this  center  may  be  no  larger  than  a  thumb,  and 
may  be  hidden  away  in  the  muscles  so  as  to  escape  detection.  Gases 
escape  from  this  mass,  but  often  remain  for  a  considerable  time 
in  the  muscle  before  reaching  the  subcutaneous    tissue. 

Weinberg  and  Seguin7  classify  the  clinical  types  of  gaseous  gan- 
grene as  (1)  classic,  (2)  toxic,  and  (3)  mixed. 

Classic  Gaseous  Gangrene. — This  is  characterized  as  having  the 
following  symptoms:  " Abundant  gas  production,  considerable 
gaseous  crepitation,  often  superficial,  bronze  tint  on  the  skin,  blebs, 
and  in  fatal  cases  septicemia  often  setting  in  a  few  hours  before 
death."  Of  this  type  of  gaseous  gangrene  the  authors  believe  B. 
perfringens  and  V.  septique,  either  singly  or  in  symbiosis,  to  be 
the  causative  agents.  Sometimes  an  extremely  toxic  organism  like 
the  B.  edematiens  may  be  associated  with  the  other  agents  in  this 
type  of  the  disease. 

Toxic  Gaseous  Gangrene. — This  type  differs  from  the  classic  in 
that  progressive,  spreading  edema  masks  the  infiltration  of  the  tis- 
sues with  gas,  and  together  with  general  symptoms  of  intoxication, 
constitutes  the  most  apparent  outward  sign  of  the  infection.  There 
is  rarely  septicemia,  even  in  fatal  cases.  So  different  is  this  type 
from  the  classic,  that  surgeons  tend  to  associate  it  rather  with  strep- 
tococcic infections  (white  erysipelas)  than  with  genuine  gaseous 
infections.  The  authors  consider  the  B.  edematiens  the  causative 
agent  of  this  form  of  the  disease,  although  they  state  that  B.  per- 
fringens sometimes  produces  similar  results.  They  give  in  detail  a 
case  in  which  the  B.  edematiens  was  responsible,  and  which  was 
cured  after  it  had  reached  an  alarming  stage  by  the  use  of  antiede- 
matiens  serum.  They  note,  however,  that  the  two  organisms  are 
often  associated,  and  that  the  action  of  one  may  disguise  the  pres- 
ence and  activity  of  the  other. 

Mixed  Gaseous  Gangrene. — This  form  includes  cases  which  pre- 
sent not  only  the  complex  flora  (B.  edematiens  and  B.  perfringens) 
but  also  the  leading  symptoms  of  the  two  preceding  varieties  (clas- 
sic and  toxic).  These  symptoms  are  usually  edema  and  gaseous 
crepitation. 

Passing  to  a  consideration  of  the  manner  of  the  infection,  the 
authors  discuss:  (1)  mechanical  factors;  (2)  bacteriological  fac- 
tors. 

Mechanical  Factors. — These  include  traumatism  and  bony  or 
vascular  lesions.  They  agree  that  all  injured  muscle  should  be  ex- 
cised as  early  as  possible,  and  they  call  attention  to  the  great 


ABSTRACTS  OF  WAR  SURGERY  149 

danger  attending  cases  complicated  by  bone  fracture.  About  three- 
fourths  of  all  fatal  cases  have  been  complicated  by  fracture.  They 
note  also  the  gravity  of  any  interruption  of  circulation,  whether 
due  to  the  nature  of  the  injury,  or  to  artificial  causes.  They  agree 
with  K.  Taylor  that  gas  pressure  is  an  important  agent  in  interrupt- 
ing the  circulation  and  in  producing  local  asphyxiation.  Especially 
serious  is  any  injury  to  the  great  vessels  which  supply  the  region  of 
the  wound.  Even  after  a  considerable  lapse  of  time  (often  weeks  or 
months)  gaseous  gangrene  has  broken  out  as  a  result  of  hindrances 
to  the  circulation. 

Bacteriological  Factors. — As  to  the  influence  of  aerobic  organ- 
isms upon  the  anaerobic  bacilli  of  gaseous  gangrene,  the  authors  are 
not  prepared  to  accept  the  conclusions  of  H.  Tissier,  who  contends 
that  B.  perfringens  and  the  anaerobic  organisms  of  gaseous  gan- 
grene in  general  are  innocuous  except  when  assisted  in  their  devel- 
opment by  aerobes.  Like  Taylor  and  others  they  have  obtained  no 
significant  results  in  laboratory  experiments  with  combinations  of 
aerobes  and  anaerobes. 

As  to  the  influence  of  anaerobic  organisms,  however,  they  are 
better  prepared  to  draw  conclusions.  They  give  briefly  the  results 
of  various  experiments  with  the  guinea  pig  in  which  the  B.  hystoli- 
cus,  associated  with  either  B.  perfringens  or  B.  edematiens,  appears 
to  favor  in  the  most  marked  manner,  the  development  of  the  infec- 
tion. This  action  the  authors  explain  by  the  characteristic  effect 
of  the  B.  hystolicus  upon  the  tissues  which  it  invades.  They  state 
that  it  transforms  vascular  connective  tissues  into  softened  hemor- 
rhagic masses  which  favor  the  growth  of  the  other  organisms  in 
the  same  manner  as  the  tissues  devitalized  by  projectiles  or  other 
agents. 

The  B.  sporogenes  also  appears  to  favor  the  growth  of  B.  per- 
fringens, but  does  so  by  a  putrid  and  gaseous  destruction  of  the 
tissues.  Similarly  V.  septique  and  B.  perfringens  stimulate  each 
other. 

The  authors  insist  especially  upon  the  fatal  nature  of  the  inter- 
action of  B.  edematiens  with  B.  perfringens,  for  the  latter  is  not 
only  stimulated  itself  by  symbiosis,  but  causes  the  B.  edematiens 
to  flourish  to  such  an  extent  that  this  organism  gains  the  upper 
hand,  and,  by  means  of  its  superior  toxicity,  is  often  responsible 
for  death.  Inoculation  of  the  guinea  pig  with  any  of  these  mixed 
cultures  produces  the  same  results  as  are  observed  clinically. 

In  conclusion  they  mention  the  sera  which  they  have  prepared 
against  the  three  most  virulent  organisms  (B.  perfringens,  V.  sep- 


150  ABSTRACTS  OF  WAR  SURGERY 

tique,  and  B.  edematiens),  and  they  state  that  the  injection  of 
these  separately  or  mixed  has  often  given  encouraging  results  as  a 
supplement  to  surgical  treatment.  They  believe  also  that  this 
mixed  serum  will  prove  more  valuable  by  way  of  prevention.  They 
hope  that  it  may  come  to  be  used  as  a  matter  of  routine  like  the 
antitetanus  serum. 

Wallace15  studied  the  subject  clinically  at  a  casualty  clearing 
station,  and   came  to  the  following  conclusions  : 

1.  It  is  rare  to  meet  gas  gangrene  without  a  muscle  injury. 

2.  It  is  chiefly  a  disease  of  the  muscles  and  is  rarely  dangerous 
unless  muscle  is  involved. 

3.  The  lesion,  in  its  early  stages,  may  be  described  as  a  longi- 
tudinal one,  running  up  and  down  the  wounded  muscles  from  the 
seat  of  the  lession  *  *  *  Muscles  and  groups  of  muscles  are  in- 
volved while  others  escape. 

4.  It  is  rare  to  find  all  the  muscles  of  a  segment  of  a  limb  in- 
volved, save  in  a  segment  distal  to  one  in  which  the  main  blood 
supply  has  been  cut  off.  Thus  the  whole  leg  dies  and  becomes 
gaseous  when  the  femoral  artery  has  been  blocked  in  the  thigh. 

5.  The  muscles  affected  are,  in  the  first  instance,  the  wounded 
ones.  If  the  pressure  caused  by  the  disease  is  relieved,  the  gangrene 
will  most  probably  be  confined  to  these  muscles,  but  if  the  pressure 
is  not  relieved  the  other  muscles  may  so  have  their  blood  supply 
checked  as  to  fall  victim  to  the  infection. 

6.  Muscles  contained  in  rigid  compartments,  such  as  the  ante- 
rior tibial  group,  are  especially  prone  to  die  if  wounded. 

7.  There  is  but  little  tendency  for  the  infection  to  pass  from 
one  muscle  to  another.  This  is  well  shown  in  amputation  stumps, 
where  one  muscle  dies  and  becomes  gaseous,  while  the  rest  of  the 
cut  muscles  remain  healthy. 

8.  The  infection  is  farther  advanced  in  the  muscles  than  in 
the  intermuscular  areolar  planes. 

9.  The  muscles  become  resonant  from  the  pressure  of  gas  long 
before  they  become  crepitant  to  the  finger,  though  this  phenomenon 

may  be  perceptible  at  an  early  date  by  means  of  the  stethoscope. 

#  #  # 

10.  The  presence  of  gaseous  crepitation  does  not  necessarily 
mean  microbic  infection.  *  *  * 

11.  Crepitation  is  usually  a  comparatively  late  phenomenon 
and  is  due  to  the  escape  of  gas  into  the  areolar  and  subcutaneous 
tissue. 

12.  In  an  infected  limb,  a  vascular  lesion  will  be  followed  by 


ABSTRACTS    OF    WAR   SURGERY  J  5  1 

the  death  of  the  muscle  or  the  muscle  group,  which  death  would  not 
have  followed  in  an  uninfected  limb.  It  is  believed  that  the  pres- 
sure produced  by  the  gas  so  raises  the  tension  in  the  limb  as  finally 
to  arrest  the  circulation. 

13.  In  an  infected  limb  there  are  several  conditions  of  the 
muscles:  (a)  Normal  purple  red  contractile  muscle  which  may  or 
may  not  be  infected  as  judged  by  cultural  experiments,  (b)  Dead, 
noncontractile,  noncrepitant  muscle  which  has  a  peculiar  red  color 
and  is  less  translucent  than  normal  muscle,  (c)  Dead,  noncon- 
tractile, crepitant  muscle  which  has  the  same  appearance  as  the 
last,     (d)  Brown,  black,  or  diffluent  muscle. 

[Muscle  dead  from  the  cutting  of  the  blood  supply  is  a  purplish 
brown  and  its  naked-eye  appearance  quite  different  from  (b)  and 

(«)]■ 

14.  The  microscopic  appearance  of  muscle  dead  from  cutting 
off  its  blood  supply  are  different  from  those  of  a  muscle  dead  from 
infection.  The  striation  is  present  in  the  former  and  absent  in 
the  latter. 

15.  The  bacteria  are  between  the  muscle  fibers  and  not  in 
them. 

16.  Microscopical  examinations  suggest  that  the  gas  may  find 
its  way  between  the  muscle  fibers  in  front  of  the  bacterial  in- 
vasion. 

17.  In  dead  infected  muscles  the  fibers  are  separated  from  one 
another.  This  separation  is  more  marked  in  muscles  that  are  crepi- 
tant than  in  those  that  have  not  yet  reached  that  stage. 

Wallace  further  calls  attention  to  the  fact  that  muscles  with  an 
intact  blood  supply  are  also  liable  to  be  killed,  although  the  method 
of  their  death  is  not  clear.  The  way  in  which  the  infection  spreads 
also  is  not  known.  The  author  believes  that  pressure  is  a  great 
factor,  but  he  is  uncertain  as  to  whether  it  acts  wholly  by  cutting 
off  the  main  blood  supply  or  by  allowing  the  gas  to  penetrate  the 
muscles  and  produce  an  anemia  of  the  individual  fibers,  or  by  favor- 
ing the  penetration  of  the  still  living  muscle  by  toxins  derived  di- 
rectly or  indirectly  from  the  bacilli. 

The  extension  of  the  infection  Wallace  believes  may  be  brought 
about  in  two  ways : 

1.  The  Toxins  Provided  By  the  Bacteria. — Most  strik- 
ing in  microscopic  section  of  the  muscles  dead  of  gas  infection 
is  the  loss  of  striation  and  the  breaking  up  of  the  muscle  fiber 
substance.  These  appearances  are  quite  different  from  those  seen 
in  uninfected  dead  muscles.    Wallace  believes  there  must  be  some 


152  ABSTEACTS  OF  WAR  SURGERY 

reason  for  this  difference  other  than  the  action  of  gas  or  the  pres- 
sure of  the  bacillus,  because  it  appears  often  to  the  same  extent 
in  microscopic  sections  in  which  few  or  many  bacilli  are  present, 
and  in  which  there  is  much  or  little  distension  due  to  the  action  of 
gas.  He  adds :  ' '  The  change  in  the  muscle  fibre  may,  therefore,  be 
due  either  to  some  toxin  produced  directly  or  indirectly  by  the 
bacteria."  Wallace  is  inclined  to  agree  with  Taylor's  theory  that 
toxins  produced  by  disintegration  of  the  muscle  substance  by  bac- 
terial action  may  supplement  the  action  of  the  exotoxins  of  the 
organism,  and  Wallace  adds  that  the  toxic  muscle  substance  pro- 
duced in  the  traumatized  portion  of  the  muscle  may  be  carried  into 
the  more  distal  parts  of  the  muscle  and  cause  its  death. 

2.  The  Part  Played  By  the  Gas. — Regarding  the  part  played  in 
the  limb,  Wallace  believes  that  nothing  but  the  rapid  evolution  of 
gas  could  possibly  account  for  the  tense  and  tympanic  state  of 
the  limb,  and  the  rapidity  with  which  this  condition  is  reached. 

In  another  communication  Wallace16  discusses  the  color  changes 
seen  in  skin  and  muscle  in  gas  gangrene,  declaring  himself  con- 
firmed in  his  support  of  Taylor's  contention  (q.  v.)  that  gas  gan- 
grene is  primarily  and  mainly  a  disease  of  muscle.  The  color 
changes  in  muscle  have  a  distinct  clinical  importance,  especially 
from  a  surgical  point  of  view,  as  is  recognized  by  Frankau,  Drum- 
mond  and  Nelligan,  Kellogg  Speed,  and  others  who  have  discussed 
the  surgical  management  of  gas  infection.  Wallace  adds  to  his 
previous  observations  a  description  of  the  naked-eye  alterations  in 
the  appearance  of  the  skin  and  muscle  in  the  sequence  in  which 
they  occur,  with  illustrative  colored  drawings. 

The  x-ray  may  be  used  to  advantage  as  an  aid  in  the  diagnosis  of 
gas  gangrene.  Lardennois  and  Pect17  have  written  an  instructive 
article  on  this  topic,  in  which  they  show  that  by  following  the  ex- 
ample of  the  Americans  and  of  Ledoux-Lebard  in  France,  they  ap- 
plied this  method  to  the  study  of  gangrenous  infections  of  war 
wounds. 

A  plate  taken  of  a  sound  limb  shows  a  gray  image  of  fleshy  masses, 
almost  homogeneous.  A  plate  taken  of  a  swollen  limb  infected  by 
the  usual  pyogenic  organisms  gives  an  aspect  only  slightly  different. 
The  image  shows  a  limb  which  is  increased  in  volume,  the  shade  is 
still  homogeneous  but  a  little  uncertain,  light  lines  mark  the  muscu- 
lar interstices. 

The  radiographic  aspect  of  a  gangrenous  limb  is  very  different. 
At  the  beginning  during  the  stage  of  malign  and  muscular  tume- 
faction it  is  easy  to  follow  the  progress  of  destruction  of  the  mus- 


ABSTRACTS  OF  WAR  SURGERY  153 

cles  around  the  infected  track,  where  a  light  zone  with  irregular 
outline  becomes  visible. 

At  the  second  stage  the  destruction  has  progressed  and  the  gan- 
grene becomes  diffuse.  One  can  then  see  on  the  plate  spots  and 
strire  delineating  the  muscular  bundles  in  course  of  digestion. 

At  a  later  stage  the  clear  spaces  are  enlarged.  The  muscular  com- 
partments appear  occupied  by  bubbles  of  irregular  outline  and  pre- 
sent a  characteristic  cloudy  aspect. 

The  radiographic  aspect  of  putrified  ischemic  gangrene  without 
gas  is  very  different.  "Wide  light  spaces  separate  the  muscles  but 
the  latter  give  a  normal  shadow. 

In  the  form  of  pure  malignant  edema,  the  image  does  not  present 
any  of  the  characteristic  aspects  that  we  have  just  described. 

To  a  competent  radiographer  the  nuoroscope  gives  the  same 
findings. 

The  information  furnished  by  a  radiographic  examination  of  gas 
gangrene  is  not  merely  of  interest  for  the  study  of  the  method  of 
destruction  by  the  anaerobes  and  the  localization  of  the  process  in 
the  muscles.  It  can  also  be  very  useful  for  the  diagnosis  of  a  point 
of  gangrene  and  even  more  for  the  evaluation  of  its  extent.  In  cer- 
tain cases  this  information  has  rendered  valuable  service  and  has 
permitted  us  to  institute  a  rational  treatment. 

Treatment. — Under  the  head  of  treatment  there  is,  fortunately, 
a  rather  striking  tendency  toward  unanimity  of  opinion.  Leriche18 
undertakes  to  establish : 

1.  That  immediate  mechanical  cleansing  of  war  wounds  suf- 
fices, without  the  use  of  antiseptics,  to  insure  the  arrest  of  serious 
infections,  and  normal  evolution  toward  healing;  this  is  accom- 
plished without  any  suppuration  if  the  operation  is  very  early, 
and  with  only  slight  suppuration  if  the  operation  is  performed 
reasonably  soon. 

2.  That  the  opening  of  infected  wounds  by  means  of  large  exci- 
sions, and  with  immediate  removal  of  all  foreign  bodies  remaining 
in  place,  and  of  organic  gangrenous  matter,  is  sufficient,  without 
antiseptics  to  arrest  the*  infectious  processes,  and  permits  of 
healing  as  early  as  is  usual  in  civil  cases. 

3.  That  disinfection  and  the  repair  and  healing  of  infected 
wounds  are  accelerated  by  the  early  and  methodical  use  of  the 
physical  agents  of  sun,  hot  air,  etc.,  without  any  recourse  to  chem- 
ical preparations. 

4.  That  in  chronic  infections  of  long  standing,  such  as  fistulae 
or  other  results  of  infection,  and  in  delayed  healing  of  the  soft 


154  ABSTRACTS  OF  WAR  SURGERY 

parts  against  which  antiseptics  are  of  no  avail,  active  surgical 
treatment  permits  of  rapid  healing  by  reason  of  the  removal  of  for- 
eign bodies,  of  sequestra,  and  of  bony  cavities,  as  well  as  by  skin 
grafts  and  the  use  of  large  autoplastic  subcutaneous  detachments. 

In  short,  the  author  declares : 

"Opening  to  the  air  in  the  fashion  of  Poncet,  by  means  of  a 
generous  and  purely  aseptic  operation,  aided  from  the  start  by 
physical  agents,  is  the  best  manner  of  treatment  for  war  wounds 
in  all  stages  of  their  development ;  these  wounds  are  not,  at  any  time 
amenable  to  chemicotherapy ;  they  arise  in  mechanical  disturbances 
and  their  treatment  should  be  physiotherapy." 

At  the  start  the  operator  should  regard  every  wound  as  suspi- 
cious, if  not  actually  infected,  and  in  every  case  should  enlarge  it, 
cleanse  it  mechanically,  and  expose  it  to  the  open  air,  according  to 
former  theories  of  primary  cleansing,  such  as  would  control  treat- 
ment in  civil  cases.  In  civil  practice  all  the  surgical  principles  nec- 
essary in  the  treatment  of  war  wounds  have  long  since  been  known 
and  put  into  practice.  Leriche  believes  that  if  war  surgeons,  like 
civil  surgeons,  will  open  deep  infected  pockets,  remove  all  centers  of 
infection,  and  provide  for  adequate  drainage  there  will  be  no  larger 
proportions  of  deaths  from  infections  in  war  than  in  times  of 
peace. 

Such  treatment,  the  author  believes,  is  especially  effective  in  deal- 
ing with  gaseous  gangrene.  The  three  wound  conditions  most  to  be 
feared  in  this  type  of  infection  are  destruction  of  muscle,  the  pres- 
ence of  foreign  bodies,  and  hidden  pockets.  Since  gas  gangrene 
is  exclusively  a  muscle  infection,  and  since  it  arises  not  from  the 
mere  presence  of  the  organism,  but  from  certain  conditions  in  the 
wound,  especially  necrosis,  which  favor  the  fatal  activity  of  the 
bacteria,  the  only  sure  way  of  dealing  with  this  infection  is  com- 
plete excision  of  the  affected  muscle.  It  suffices,  however,  to  remove 
only  the  toxic  and  gangrenous  tissue  with  the  whole  zone  of  the 
infection.  Generally  the  infectious  process  is  confined  to  a  single 
muscle,  although  the  gas  may  have  extended  far  beyond. 

In  case  of  injury  to  the  blood  vessels,  Leriche  urges  removal  of 
all  hematoma,  and  the  application  of  ligatures  to  the  vessels  so  as 
to  leave  no  media  for  infection  in  the  wound. 

With  regard  to  the  bones,  Leriche  insists  upon  the  removal  "not 
only  of  free  bone  fragments  in  the  wound,  and  of  bone  splinters  on 
which  bits  of  garments  are  sometimes  found,  but  also  of  adherent 
splinters  with  a  vital  periosteum,  the  health  of  which  might  be  en- 


ABSTRACTS  OF  WAR  SURGERY  L55 

dangered  by  infection,  and  which  might  hinder  the  ventilation  of 
the  fracture." 

The  author  reviews,  with  considerable  detail,  his  own  extended 
experience  in  dealing  with  war  wounds.  Out  of  about  2,000  limb 
wounds  treated  according  to  these  principles  practically  no  cases  of 
serious  infection  occurred,  except  when  the  operation  was  incom- 
plete, or  certain  fragments  of  foreign  matter  were  overlooked.  He 
believes  that  the  surgeon  ' '  ought  not  to  proceed  according  to  imme- 
diate clinical  indications  of  infection,  but  with  a  view  to  the  possi- 
bilities of  its  development." 

By  way  of  postoperative  treatment  he  urges  recourse  first  of 
all  to  heliotherapy,  and  testifies  to  the  remarkable  and  immediate 
results  of  this  method  of  dealing  with  infected  surfaces  which  are 
properly  exposed.  If  sun  treatment  is  impossible,  hot  air  and 
artificial-light  methods,  although  not  so  effective,  are  sure  to  give 
good  results. 

Frankau,  Drummond,  and  Nelligan19  recommend  early  resec- 
tion of  the  infected  muscles  as  a  conservative  measure.  The 
authors  have  based  their  work  upon  the  observations  made  by 
Wallace,  especially  to  the  effect  that  gas  gangrene  is  chiefly 
a  disease  of  the  muscles ;  that  it  rarely  invades  all  the  muscles  of 
a  limb,  except  in  a  segment  completely  cut  off  from  blood  supply ; 
that  it  progresses  longitudinally ;  that  there  is  little  tendency  for 
the  infection  to  pass  from  one  muscle  to  another.  The  authors 
believe  that  these  points  can  not  be  controverted. 

They  have  made  it  a  point  first  to  explore  the  primary  focus 
so  as  to  arrest  infection  by  a  resection  of  the  infected  areas.  Such 
resection  may  involve  a  part  or  the  whole  of  single  muscles  or 
groups  of  muscles. 

Eesection  should  be  limited,  however,  to  limbs  in  which  the 
main  blood  vessel  is  intact,  and  which  would  be  worth  more  than 
an  artificial  limb  when  saved;  otherwise  amputation  should  be 
preferred.  Resection  of  large  groups  of  muscle  is  to  be  chosen, 
nevertheless,  if  amputation  involves  too  great  a  risk  of  life.  The 
resection  should  extend  until  muscle  is  reached  with  normal 
color,  normal  contractibility,  and  a  good  blood  supply.  Even  if 
there  is  still  infection  in  such  muscles,  the  opening  of  the  wound 
and  free  drainage  arrests  further  development. 

After  resection,  the  following  treatment  is  applied:  (1)  The 
dressings  are  reduced  to  the  minimum ;  that  is,  one  or  two  layers 
of  gauze  are  placed  over  the  wound  so  as  to  allow  free  access  of 
air,  and,  if  possible,  sunshine  to  the  wound  region;  (2)  constant 


156  ABSTRACTS  OF  WAR  SURGERY 

or  intermittent  irrigation  of  the  wound  by  some  modification  of 
the  Carrel  method — eusol,  saline,  or  hydrogen  peroxide  being  used 
as  the  irrigating  fluid. 

The  authors  detail  14  cases  in  which  such  treatment  has 
given  excellent  results.  They  call  attention  especially  to  one 
case  in  which  the  removal  of  only  half  of  a  muscle  was  necessary, 
because  the  infection  showed  no  disposition  to  progress  trans- 
versely. They  also  cite  several  cases  in  which  generous  resection 
took  the  place  of  amputations  that  would  surely  have  proved 
fatal. 

Basing  his  views  upon  bacteriologic  and  histologic  findings, 
Kellogg  Speed,20  Major,  M.  R.  C,  United  States  Army,  France, 
recommends  early  and  radical  operation.  When  the  discharge 
from  a  gunshot  wound  stimulates  gas  infection,  when  pain  and 
swelling  are  out  of  proportion  to  the  size  of  the  wound  tract, 
gas  bubbles  can  be  expressed  by  slight  pressure,  and  the  toxic 
condition  is  supervening,  one  should  at  least  explore  thoroughly 
the  suspected  gaseous  area.  Excision  of  the  tousled  tissue  of  the 
wound  of  entrance  one-half  inch  from  the  margin  is  first  per- 
formed. Constrictors  should  never  be  applied,  because  even  a 
temporary  arrest  of  the  circulation  may  lead  to  a  rapid  spread 
of  the  infection.  If  wounds  of  exit  and  entrance  are  both  pres- 
ent, they  are  treated  alike  regardless  of  location  or  extent.  The 
affected  tissue  should  then  be  laid  open  by  a  bold  incision  con- 
necting the  two  wounds  if  present,  or  in  the  long  axis  of  an  ex- 
tremity, if  an  entrance  penetration  wound  alone  exists.  Dam- 
aged infected  muscle  is  then  removed  either  by  sharp  or  finger 
dissection,  through  normal  planes  of  cleavage  as  much  as  can 
possibly  be  done  without  the  opening  of  uninvolved  muscles  of 
fascial  areas.  It  is  unusual  to  find  all  the  muscles  of  a  limb 
involved  unless  the  main  blood  supply  has  been  cut  off.  Nor  does 
infection  tend  to  travel  into  neighboring  muscles,  unless  they 
have  been  damaged  by  the  missile. 

Very  extensive  dissections  which  disregard  the  future 
function  of  a  limb  are  indicated,  according  to  Speed,  when  the 
patient's  condition  or  other  factors  will  not  warrant  amputa- 
tion. In  the  presence  of  gunshot  fractures,  these  excisions,  fol- 
lowed by  suitable  splinting  and  extensions,  lead  to  favorable 
results.  If  the  mutilation  is  such  as  to  render  the  limb  func- 
tionally useless,  amputation  is  best,  provided  the  patient's  con- 
dition permits.  The  use  of  spinal  anesthesia  (stovain)  in  lower 
extremity  surgery  should  not  be  overlooked  when  amputation 
shock  is  to  be  avoided. 


ABSTRACTS  OF  WAR  SURGERY  157 

The  muscle  excision  should  be  carried  to  the  point  at 
which  the  fibers  remain  uncolored  by  the  advancing  infection — 
until  the  muscle  belly  jerks  under  the  cutting  knife,  or  until 
normal  contractility  is  found,  and  until  bloody  oozing  from  the 
cut  muscle  bundles  indicates  a  healthful  blood  supply.  These 
operative  steps,  which  are  limb  and  life  saving  devices,  must  be 
thoroughly,  rapidly,  and  anatomically  performed.  A  small 
amount  of  tissue  hemorrhage  is  not  disturbed  by  the  operator; 
large  bleeding  points  must  be  ligated,  but  the  amount  of  circu- 
lation present  should  be  left  undisturbed  as  much  as  possible  by 
operative  manipulation.  These  wounds  should  be  left  wide  open 
without  suture,  and  for  the  most  part  should  be  treated  by  the 
Carrel-Dakin  method  until  danger  of  extension  is  past,  or  by 
warm  baths  selected  by  the  surgeon.  The  leucocyte  infiltration 
and  outpour  of  pus  mean  an  end  to  the  gas  infection. 

Taylor9  outlines  the  treatment  of  gas  gangrene  as  follows: 

1.  Prophylactic  treatment  during  the  dormant  stage. 

2.  Treatment  during  the  stage  of  gaseous  distention. 

3.  Treatment  of  accomplished  gangrene. 

Prophylactic  Treatment  During-  the  Dormant  Stage. — This 
includes:  First,  an  attempt  toward  the  removal  or  destruction 
of  the  bacteria  present  in  the  wound  and  toward  depriving  them 
of  their  necessary  soil,  the  dead  muscle;  second,  the  institution 
of  precautionary  measures  against  the  occurrence  of  gaseous 
distention.  Time  is  an  important  factor.  The  shorter  the  inter- 
val between  injury  and  treatment  the  more  certain  is  a  success- 
ful result.  Thorough  cleansing  of  the  fresh  wound  is  necessary, 
including  the  removal  of  all  foreign  bodies  possible.  (Under 
"foreign  bodies"  we  include  dirt,  fragments  of  cloth,  fragments 
of  bone,  and  also  any  portions  of  muscle  showing  signs  of  necro- 
sis.) Following  the  cleansing  of  the  wound,  the  use  of  an  anti- 
septic active  against  the  gas  bacillus  is  clearly  indicated.  For 
this  purpose  Taylor  recommends  a  one-tenth  per  cent  solution 
of  quinine  hydrochloride  in  physiological  saline  as  effective 
clinically.  * 

Oxygen,  injected  subcutaneously,  can  not  reach  the  seat 
of  the  infection  in  the  muscle,  and  it  probably  only  increases 
the  difficulties  of  circulation  and  tends  to  give  a  wrong  idea  of 
the  extent  of  the  gas  formed  by  the  bacilli. 

The  use  of  antisera  and  vaccines  is  of  doubtful  value,  if  we 
consider  the  organism  as  a  saprophyte,  which    has    not    invaded 


158  ABSTRACTS  OF  WAR  SURGERY 

living  tissue,  and  the  damage  done  to  the  tissues  as  of  a  mechan- 
ical nature.  It  is  also  very  uncertain  that  the  muscle — toxic, 
hemolytic  principle  formed  by  the  bacteria  is  a  true  soluble  exo- 
toxin for  which  an  antitoxic  serum  can  be  produced. 

Treatment  During  the  Stage  of  Gaseous  Distension. — This 
stage  is  marked  by  increasing  intramuscular  pressure,  which  may 
result  in  the  speedy  death  of  the  muscle.  The  pressure  should 
therefore  be  relieved  at  the  earliest  possible  moment.  It  is  neces- 
sary to  practice  more  incisions  for  the  release  of  gaseous  pressure 
than  are  needed  for  the  draining  of  exudates.  It  is  highly  im- 
portant, if  possible,  to  find  the  focus  of  necrotic  tissue  where  the 
gas  is  being  formed  and  to  remove  all  necrotic  portions.  Post- 
operative treatment  should  be  similar  to  that  mentioned  above. 

Treatment  of  Gangrene. — If  incisions  into  the  muscle  show 
a  pale,  dry,  dull  pink  surface,  and  a  consistency  as  if  wrung 
dry  of  blood  and  lymph,  the  condition  of  gangrene  is  probably 
accomplished.  The  dead  muscle  is  then  a  great  menace  to  the 
patient,  first,  because  it  will  speedily  become  an  active  source  of 
gas  production  by  the  rapid  invasion  of  the  bacilli,  and  secondly, 
because  the  products  of  autolysis  of  a  large  mass  of  tissue  may 
of  themselves  produce  a  profound  toxemia.  Muscle  in  this  con- 
dition will  never  regain  its  vitality.  If  the  patient  lives,  it  will 
be  found  to  slough  out  in  large  fragments,  sometimes  as  an  entire 
muscle.  Hence  the  treatment  indicated  is  to  remove  the  gan- 
grenous tissue  as  quickly  and  as  thoroughly  as  possible.  This 
can  usually  be  done  only  by  amputation,  if  the  process  is  in  an 
extremity.  No  attempt  should  be  made  to  cover  the  stump  with 
skin  flaps.  The  transverse  section  of  the  muscle  fibers  allows 
of  free  drainage  of  gas,  and,  unless  extensive  necrosis  has 
occurred  in  the  muscle  tissues  remaining,  the  process  is  fre- 
quently checked.  The  presence  of  subcutaneous  crepitus  above 
the  possible  limit  of  amputation,  or  even  the  presence  of  muscle 
involvement  above  that  line,  does  not  mean  that  the  process  will 
continue  after  the  operation. 

Wallace15  bases  on  his  clinical  experience  the  following  four 
conclusions  regarding  treatment : 

(a)  The  avoidance  of  all  pressure  or  other  hindrance  to  cir- 
culation, and  recommends  especially  that  all  hemorrhages  and 
hematomata  be  hunted  out  and  corrected.  In  cases  involving  the 
injury  or  thrombosis  of  great  vessels  he  urges  that  an  attempt 
be  made  to  suture  rather  than  resort  to  ligature.  Tuffier's  tube 
may  be  serviceable. 


ABSTRACTS  OF  WAR  SURGERY  159 

(b)  In  considering  amputation  it  is  well  to  remember  that 
only  the  wounded  muscle  is  likely  to  be  infected  with  gaseous 
gangrene,  and  that  excision  or  the  ablation  of  this  muscle  usually 
suffices  to  arrest  infection.  This  is  not  so  easily  accomplished, 
however,  in  the  thigh  as  in  the  leg,  in  which  case  it  is  fairly  easy 
to  save  the  limb  by  the  ablation  of  the  anterior  tibial  group.  The 
same  holds  true  for  the  muscles  of  the  forearm.  The  brick  red 
color  and  the  noncontractibility  will  show  at  once  which  muscles 
are  past  saving. 

(c)  "When  gas  gangrene  occurs  in  a  segment  of  a  limb  distal 
to  the  segment  wounded  it  nearly  always  means  that  the  main 
artery  is  blocked  and  amputation  of  the  gangrenous  segment  is 
the  only  course. 

(d)  "Wallace  warns  against  taking  the  extent  of  crepitation 
of  the  skin  as  an  indication  for  amputation,  for  it  may  not  neces- 
sarily indicate  a  state  of  infection  requiring  such  drastic  treat- 
ment. The  surgeon  before  deciding  should  determine  accurately 
the  exact  condition  of  the  muscles  and  the  number  involved. 
Otherwise  many  limbs  may  be  sacrificed  when  the  removal  of 
only  a  single  muscle  might  serve  to  check  the  infection. 

One  of  the  newer  phases  of  the  treatment  of  gas  gangrene 
is  the  use  of  serum.  In  1916  Weinberg21  published  a  paper  on 
this  subject,  stating  that  at  the  beginning  of  the  war  he  and  his 
associates  prepared  an  anti  B.  perfringens  (aerogenes  capsula- 
tus)  vaccine  which  seemed  to  yield  good  results  in  cases  of  sub- 
acute gas  gangrene  in  which  the  B.  perfringens  was  the  most 
pathogenic  organism.  The  author  believes,  however,  that  the 
best  vaccine  would  be  one  prepared  with  all  the  organisms,  both 
aerobes  and  anaerobes,  to  be  found  in  the  wounds.  Such  vaccine 
could  not  be  prepared  by  the  classic  method,  because  the  spores 
resist  the  temperature,  but  it  has  been  produced  by  treating  the 
mixture  of  organisms  with  iodine.  Since  the  vaccine  should  be 
used  at  the  earliest  possible  moment,  the  author  prepares  the 
omnivalent  iodized  autovaccine  from  the  wound  discharge  with 
a  delay  of  not  more  than  two  hours.  Several  injections  are  made 
daily  or  every  two  days.  Later,  if  thought  best,  an  autovaccine 
may  be  prepared  with  cultures  of  the  isolated  organisms. 

Weinberg  believes  that  this  treatment  should  be  employed 
as  a  supplement  to  the  large  excision  and  antiseptic  methods, 
but  he  believes  that  it  has  yielded  good  results. 

Weinberg  tells  of  a  serum  obtained  from  horses  after  B. 
perfringens  had  been  injected  for  a  year.  Although  the  activity 
of  this   serum   is   comparatively   small,   it   has    given   excellent 


160  ABSTRACTS  OF  WAR  SURGERY 

results  in  a  number  of  eases,  although,  it  appears  powerless 
against  septicemia. 

Similarly  antitoxic  sera  of  the  Vibrion  septique  and  B.  ede- 
matiens  have  been  prepared.  On  the  whole  the  results  of  such 
experiments  .have  been  disappointing,  and  the  sera  difficult  to 
obtain. 

The  Use  of  the  Serum  of  Leclainche  and  Vallee. — Weinberg 
speaks  favorably  also  of  the  use  of  Leclainche 's  and  Vallee 's 
polyvalent  serum,  especially  in  wounds  infected  with  strepto- 
cocci. The  use  of  this  serum  for  gas  gangrene  is  mentioned  favor- 
ably by  M.  Quenu,  M.  L.  Bazy,  and  M.  Eoutier  in  a  discussion 
of  a  paper  on  the  "Reappearance  of  gaseous  gangrene  in  second- 
ary amputations"  (Archives  de  Medecine  et  de  Pharmacie  Mili- 
taires,  March,  1917,  p.  402). 

Bull  and  Pritchett,1  having  demonstrated  that  the  toxic 
products  of  the  growth  of  B.  welchii  exhibit  antigenic  activities 
and  readily  give  rise  to  the  formation  of  active  antitoxic  sub- 
stances, next  investigated  the  question  of  whether  the  immune 
serum  developed  possessed  protective  and  curative  properties. 
Their  investigations  in  this  direction  indicate  that  in  B.  welchii 
infection  in  nature,  the  development  of  the  spores  into  vegative 
bacilli  may  be  prevented  by  protective  inoculation  of  an  anti- 
toxic serum,  and  also  that  the  vegetative  bacilli  may  be  deprived 
of  their  toxic  products,  which  appear  to  be  their  real  offensive 
instrument. 

Thus,  not  only  is  there  developed  a  new  point  of  view  regard- 
ing the  manner  of  the  pathogenic  action  of  the  Welch  group  of 
bacilli,  but  there  is  provided  a  new  means  of  combating  their 
pathogenic  effects. 

Following  this  new  therapeutic  suggestion,  Bull22  conducted 
a  more  extensive  and  systematic  series  of  experiments  with  ref- 
erence to  the  preventive  and  curative  powers  of  the  antitoxin. 
The  highly  suggestive  experimental  results  thus  obtained  derive 
their  significance  from  the  fact  that  B.  welchii  infections  in 
guinea  pigs  and  other  susceptible  animals  are  comparable  with 
infections  with  this  organism  in  man.  The  experimental  infec- 
tions in  the  guinea  pig  differ,  however,  from  the  natural  infection 
in  man. 

The  possibilities  of  this  passive  serum  protection  has  natural 
limits  of  time,  depending  upon  the  rapidity  of  elimination  of  the 
foreign  serum.  The  experimental  data  presented,  which  agree 
with  the  experience  with  antidiphtheritic  and  antitetanic  anti- 


ABSTRACTS  OF  WAR  SURGERY  101 

toxins,  indicate  that,  in  all  probability,  a  passive  immunity  to  B. 
welchii  infection  of  at  least  two  weeks'  duration  can  be  conferred 
upon  a  man  by  a  single  injection  of  the  antitoxin.  This  immunity 
will  be  sufficient  in  the  majority  of  instances,  since  only  sporadic 
cases  of  B.  welchii  infection  arise  later  than  the  tenth  day  after 
injury,  and  the  greater  number  occur  within  48  hours  of  that 
time. 

In  the  light  of  the  results  obtained  in  treating  the  infection 
in  guinea  pigs,  it  is  reasonable  to  hope  that  the  antitoxin  will  be 
of  value  also  as  a  therapeutic  agent.  The  indications  are  that 
early  infectious  cases  can  be  readily  arrested  and  the  more 
advanced  and  severe  ones  ameliorated,  if  not  wholly  checked,  so 
that  surgical  interference  may  be  resorted  to  with  greater  prob- 
ability of  effectiveness. 

The  antitoxin  in  man  should  be  administered  intravenously 
and  probably  locally,  about  the  wound,  as  well. 

In  a  later  communication  Bull  and  Pritchett23  detail  at 
length  a  series  of  experiments  with  22  additional  strains  of  B. 
welchii,  collected  from  widely  different  sources,  and  tested  with 
regard  to  toxin  production.  It  was  found  that  each  strain  pro- 
duces a  toxin  which,  on  animal  inoculation,  gives  rise  to  lesions 
comparable  in  every  respect  to  those  produced  by  the  toxins  pre- 
viously reported  on,  and  each  toxin  was  neutralized  by  an  im- 
mune (antitoxic)  serum  produced  with  one  of  the  former  toxins. 
The  toxins  obtained  from  the  several  individual  strains  varied  in 
potency,  the  lethal  dose  ranging  from  0.3  to  3  c.c. 

The  antitoxin  for  B.  welchii  toxin  can  apparently  be  pre- 
pared from  a  single  strain  of  the  organism  which  yields  under  the 
conditions  described  a  high  titer  of  toxin,  and  this  antitoxin  can 
be  employed  to  combat  infection  with  or  prevent  infection  by 
any  strain  whatever  of  the  bacillus. 

The  report  of  the  Third  Interallied  Surgical  Conference,  held 
in  November,  1917,  did  not  furnish  a  very  enthusiastic  outlook 
for  the  serum  treatment  of  gas  gangrene.  This  conference 
reported  as  follows: 

Because  of  accidents,  in  some  cases  of  gas  gangrene,  an 
alkaline  treatment*  has  been  instituted.  This  may  be  for  the 
purpose  of  rendering  a  later  operation  possible  in  the  case  of 
patients  whose  condition  does  not  permit  of  a  primary  operation ; 
or  it  may  be  employed  for  disintoxication.     Encouraging  results 


*  Intravenous  injection  of  500  grams  of  the  following  solution,   sterilized  in 
the  autoclave:     Bicarbonate  of  soda,  50  grams;  distilled  water,  to  1,000. 


162  ABSTRACTS  OF  WAR  SURGERY 

have  been  obtained  by  this  treatment.    Further  attempts  should 
be  made  in  this  direction. 

Some  cases  have  been  treated  by  various  specific  sera:  anti- 
Perfringens,  anti-Vibrion  septique,  anti-Bellonensis. 

These  three  sera  have  produced  no  unfavorable  results. 

The  anti-Perfringens  serum,  which  has  been  used  prevent- 
ively in  several  cases,  seems  to  have  given  encouraging  results. 
As  a  cure  it  has  been  sufficiently  successful  to  warrant  further 
attempts. 

The  use  of  anti-Vibrion  septique  and  anti-Bellonensis  has 
given  very  marked  results,  by  way  of  cure  as  well  as  of  preven- 
tion, even  when  administered  in  very  advanced  stages  of  toxic 
forms  of  the  disease.    These  results  make  further  tests  desirable. 

Bibliography. 

lBull,  Carroll  G.,  and  Pritchett,  Ida  W. :  Toxin  and  Antitoxin  of  and  Pro- 
tective Inoculation  Against  Bacillus  welchii,  Jour.  Exper.  Med.,  July, 
1917,  xxvi,  No.  1,  p.  119. 

2Taylor,  Kenneth:  Factors  Responsible  for  Gaseous  Gangrene,  Lancet, 
London,  January  15,  1916,  (Abs.  from  Med.  Bull.*). 

3Heitz-Boyer:  Hematoma  and  Gaseous  Gangrene,  Arch.  d.  M6d.,  et  d. 
Pharmacie  Militaires,  November,  1916,   (Abs.  from  Med.  Bull.). 

4Ivens,  H.  F.:  A  Clinical  Study  of  Anaerobic  Wound  Infection,  Lancet, 
London,  December  23,  1916,  p.  1058,  (Abs.  from  Med.  Bull.). 

5Dalvell,  E.  J.:  A  Case  of  Gas  Gangrene  Associated  with  B.  edematiens, 
Brit.  Med.  Jour.,  March  17,  1917,  (Abs.  from  Med.  Bull.). 

^Douglas,  S.  R.,  Fleming,  A.,  and  Colebrook,  L.:  Studies  in  Wound  Infec- 
tions: On  the  Question  of  Bacterial  Symbiosis  in  Wound  Infections, 
Lancet,  London,  April  21,  1917,  (Abs.  from  Med  Bull.). 

^Weinberg,  M.  and  Seguin,  P.:  Studies  Concerning  Gaseous  Gangrene, 
Ann.  d.  l'lnst.  Pasteur,  September,  1917,  xxxi,  442,  (Abs.  from  Med. 
Bull.). 

8Emery,  W.  d'Este:  Some  Factors  in  the  Pathology  of  Gas  Gangrene, 
Lancet,  London,  May  6,  1916,  (Abs.  from  Med.  Bull.). 

9Taylor,  Kenneth:  Gas  Gangrene:  Its  Course  and  Treatment,  Bull. 
Johns  Hopkins  Hosp.,  October,  1916,  xxvii,  No.  308,  (Abs.  from  Med. 
Bull.). 
lOMullally,  G.  T.,  and  McNee,  J.  W.:  A  Case  of  Gas  Gangrene  Exhibit- 
ing Unusual  Proofs  of  a  Blood  Infection,  Brit.  Med.  Jour.,  April  1,  1916, 
(Abs.  from  Med.  Bull.). 
HHartley,  J.  N.  J.:     Metastatic  Gas  Gangrene,  Brit.  Med.  Jour.,  April  14, 

1917,   (Abs.  from  Med  Bull.). 
i2McNee,  J.  W.,  and  Dunn,  J.  Shaw:     The  Method  of  Spread  of  Gas  Gan- 
grene into  Living  Muscle,  Brit.  Med.  Jour.,  June  2,  1917,   (Abs.  from 
Med.  Bull.). 
i3Bashford,  E.  F.:     General  Pathology  of  Acute  Bacillary  Gangrene  Arising 
in  Gunshot  Injuries  of  Muscle,   Brit.  Jour.   Surg.,  April,   1917,    (Abs. 
from  Med.  Bull.). 
i^Sacquepee,  M.  (Reported  by  E.  Quenu) :     A  Form  of  Gaseous  Gangrene, 
with  Special  Reference  to  Malignant  Gaseous  Edema,  Bull,  et  Mem. 
Soc.  de  Chir.  de  Paris,  June  1,  1915,  (Abs.  from  Med.  Bull.). 
loWallace,  Cuthbert  S.:     Gas  Gangrene  as  Seen  at  the  Casualty  Stations, 
Jour.  Roy.  Army  Med.  Corps,  May,  1917,  (Abs.  from  Med.  Bull.). 


*The  Medical  Bulletin.  A  Review  of  War  Medicine,  Surgery,  and  Hygiene. 
December,  1917.  Vol.  1,  No.  2.  Published  by  the  American  Red  Cross  Society 
in  France. 


ABSTRACTS    OF   WAR   SURGERY  163 

iGWallace,  Cuthbert:  The  Color  Changes  Seen  in  the  Skin  and  Muscle  in 
Gas  Gangrene,  Brit.  Med.  Jour.,  June  2,  1917,  (Abs.  from  Med.  Bull.). 

iTLardonnois,  G.,  and  Pech.:  Radiographic  Aspects  of  Gangrenous  Infec- 
tions of  War  Wounds  and  of  Gas  Gangrene  in  Particular,  Jour,  de 
Radiologic  et  d'Electrologie,  May-June,  1917,  (Abs.  from  Med.  Bull.). 

i8Leriche,  R.:  Aseptic  and  Physical  Means  of  Treatment  for  War  Wounds 
in  Various  Stages,  Lyon  Chirurgical,  January-February,  1916,  (Abs. 
from  Med.  Bull.). 

i9Frankau,  C.  H.  S.,  Drummond,  Hamilton,  and  Nelligan,  G.  E.:  The  Suc- 
cessful Conservative  Treatment  of  Early  Gas  Gangrene  in  Limbs  by 
the  Resection  of  Infected  Muscles,  Brit.  Med.  Jour.,  June  2,  1917, 
(Abs.  from  Med.  Bull.). 

20Speed,  Kellogg:  Localized  Gas  Infections  in  War  Wounds  Treated  by 
Muscle  Group  Excision,  Jour.  Am.  Med.  Assn.,  January  26,  1918,  p.  225. 

2iWeinberg,  M.:  Treatment  of  Gaseous  Gangrene  by  the  Use  of  Serum, 
Proc.  Roy.  Soc.  Med.,  1916,  ix,  p.  119,  (Abs.  from  Med.  Bull.). 

22Bull,  Carroll  G.:  The  Prophylactic  and  Therapeutic  Properties  of  the 
Antitoxin  for  Bacillus  welchii,  Jour.  Exper.  Med.,  October,  1917,  xxvi, 
No.  4,  p.  603. 

23Bull,  Carroll  G.,  and  Pritchett,  Ida  W.:  Identity  of  the  Toxins  of  Differ- 
ent Strains  of  Bacillus  welchii  and  Factors  Influencing  their  Produc- 
tion in  Vitro,  Jour.  Exper.  Med.,  December,  1917,  xxvi,  No.  6,  p.  867. 

GAS  PHLEGMONS  ON  THE  FIELD.— G.  Seefisch.  Deutsch. 
med.  Wchnschr.,  1915,  xli,  p.  256. 

Gas  phlegmons,  which  are  frequently  observed  after  injuries 
from  artillery  fire,  very  frequently  lead  to  gangrene,  but  the 
prognosis,  even  when  there  is  very  great  development  of  gas  is 
not  bad  if  extensive  incisions  are  promptly  made  into  healthy 
tissue.  Amputation  must  be  performed  near  the  boundary  of 
the  gangrene,  and  care  must  be  taken  to  make  a  useful  stump; 
secondary  suture  should  be  performed  as  soon  as  possible — 
within  the  first  week. 

If  a  gas  phlegmon  is  recognized  early  and  free  incisions 
made,  gangrene  can  be  prevented.  Seefisch  has  treated  12  severe 
cases  of  gangrene  on  these  principles  without  losing  one,  and 
most  of  them  could  be  discharged  within  a  few  weeks  with  a  good 
stump  almost  completely  healed.  Of  course  most  of  the  cases 
of  gas  phlegmon,  and  the  severest  ones,  are  seen  in  the  field  hos- 
pitals, where  it  is  difficult  to  give  oxygen  treatment,  because  the 
physicians  are  so  overwhelmed  with  the  numbers  of  wounded 
brought  in  during  the  day  that  there  is  no  time  for  it.  The  cases 
may  be  irrigated,  however,  with  hydrogen  peroxide. 

TREATMENT   OF    GAS   PHLEGMON   IN   THE    FIELD.— W. 

Becker.    Med.  Klin.,  1915,  xi,  p.  329. 

The  author  treats  superficial  wounds  by  painting  the  sur- 
rounding skin  with  tincture  of  iodine  and  irrigating  the  wounds 
with  three  per  cent  hydrogen  peroxide.     Dry  dressings  should 


164  ABSTRACTS  OF  WAR  SURGERY 

always  be  used,  as  moist  dressings  favor  the  development  of  bac- 
teria. Pockets  and  cavities  should  be  kept  open.  Unnecessary 
dressings  and  too  early  transportation  should  be  avoided,  for 
rest  and  fixation  are  the  best  treatment.  During  the  dry  weather 
of  the  first  few  months  of  the  war  there  was  little  severe  infec- 
tion, but  after  the  rains  set  in  and  the  wounds  were  soiled  with 
mud  from  the  trenches  conditions  were  much  worse.  The  per- 
centage of  tetanus  infections  was  very  high,  and  in  spite  of  the 
administration  of  tetanus  antitoxin,  the  majority  of  the  patients 
died. 

Gas  phlegmon  is  more  unusual.  It  is  distinguished  by  a  cop- 
per color  of  the  skin,  rapidly  increasing  edema,  and  in  the  worst 
cases,  gangrene.  The  danger  lies  in  the  rapidity  of  its  develop- 
ment. The  mortality  is  at  least  four-fifths  of  the  total  number 
of  cases.  Three  cases  are  described  illustrating  the  rapidity  of 
development  of  gangrene.  After  gangrene  has  developed  ampu- 
tation is  the  only  treatment ;  if  the  cases  are  seen  early  and  treat- 
ment given  at  once,  insufflation  of  oxygen  is  effective.  It  is 
difficult  to  keep  a  supply  of  oxygen  at  the  front,  but  the  author 
suggests  that  an  abundant  supply  of  oxygen  tanks  be  kept  at  a 
field  hospital  as  near  as  possible  to  the  lines  and  the  wounded 
rushed  to  it  as  quickly  as  possible  by  automobile. 


ABDOMEN 

A  SERIES  OF  500  CASES  OF  EMERGENCY  OPERATIONS 
FOR  ABDOMINAL  WOUNDS.— C.  F.  Walters,  H.  D.  Rol- 
linson,  A.  R.  Jordan,  and  A.  G.  Banks.  Lancet,  London, 
1917,  cxcii,  p.  207. 

The  500  cases  were  operated  upon  at  a  clearing  station 
near  the  fighting  line  in  a  house  with  steam  heat,  which  already 
had  one  operating  room  to  which  another  was  quickly  added. 
The  report  is  more  of  an  attempt  to  summarize  results  of  experi- 
ence in  diagnosis  and  treatment  than  to  attempt  an  elaborate 
description  of  them. 

The  patients  were  received  as  early  as  three  hours  after  being 
shot,  but  some  were  received  after  the  lapse  of  a  greater  length 
of  time. 

Time  Element  in  Prognosis  and  Treatment. — The  authors 
state  that  an  abdominal  patient's  chances  diminish  with  every 
hour  of  delay.  The  vast  majority  received  hospital  care  in 
8  to  10  hours,  and  a  large  percentage  in  half  that  time.  Some 
arrived  three  to  four  days  after  they  were  shot.  These  late  cases 
are  usually  inoperable,  the  visceral  injury  is  not  severe  and 
nature  has  made  an  effort  to  deal  with  the  condition.  In  cases 
wounded  four  or  five  days,  with  general  peritonitis,  the  practice 
was  to  drain  the  pouch  of  Douglas  through  a  small  incision.  In 
cases  where  intestinal  wounds  had  healed  recovery  followed. 

The  authors  recognized  that  in  this  war,  as  in  other  recent 
wars  since  the  adoption  of  the  armored  rifle  bullets,  not  all  cases 
of  perforating  wounds  of  the  abdomen  are  fatal  and  "that  severe 
visceral  injuries  can  be  and  are  cured  by  natural  means."  Still, 
operation  is  believed  to  enormously  increase  the  patient's  chances 
of  recovery.  The  mortality  of  a  large  number  of  cases  operated 
upon  is  fixed  at  about  50  per  cent  and  although  there  is  no  data 
in  this  war  on  which  to  base  the  mortality  of  unoperated  cases, 
the  authors  have  reason  to  believe  that  it  would  be  somewhere 
in  the  region  of  90  per  cent. 

In  the  diagnosis  and  prognosis  of  patients  on  admission,  two 
questions  arise:  (1)  Is  the  patient  able  to  stand  operation? 
(2)  Is  he  suffering  from  a  true  penetrating  abdominal  wound 
with  injury  to  hollow  viscus? 

165 


166  ABSTRACTS  OF  WAR  SURGERY 

In  answering  the  first  question,  the  patients  exhibiting  the 
two  extremes  are  soon  passed  upon:  (1)  The  obviously  mori- 
bund man — cold,  pulseless,  and  dying— offers  no  difficulty  in  com- 
ing to  a  decision.  Operation  on  a  patient  in  this  condition  can 
not  be  considered.  (2)  On  the  other  hand  there  is  no  doubt  of 
the  patient's  ability  to  stand  operation,  if  his  condition  is  good,  and 
he  has  been  shot  only  four  or  five  hours  before  examination. 
Whether  the  case  is  doubtful  as  to  the  actual  presence  of  a  per- 
forating wound,  it  is  always  one  for  exploratory  operation  at 
least,  because  the  shock  of  laparotomy  is  not  considered  harmful 
in  such  cases. 

The  chief  difficulty  in  deciding  whether  the  patient  is  able 
to  stand  operation  is  found  in  patients  who  occupy  the  middle 
ground  between  those  discussed — those  whose  condition  is  poor, 
who  have  received  their  wounds  hours  before.  If  serious  visceral 
injury  is  certain,  as  in  the  case  of  protruding  intestines,  operation 
is  in  order  unless  the  patient  has  reached  the  moribund  stage. 
Such  a  patient  may  improve  if  kept  in  a  ward,  warm  and  at  rest, 
for  one  or  two  hours.  His  condition  is  then  more  favorable  for 
operation.  If  he  fails  to  rally  in  that  time — in  two  hours — he 
seldom  recovers  sufficiently  to  be  operable  in  less  than  thirty 
or  forty  hours. 

In  regard  to  the  second  question — "Is  he  suffering  from  a 
true  penetrating  abdominal  wound  with  injury  to  hollow  vis- 
cus?"  There  are  cases  of  severe  injury  to  a  hollow  viscus  with- 
out penetration  of  the  peritoneum — in  cases  for  instance  in  which 
the  abdominal  wall  has  been  bared  by  a  passing  shot.  Again,  in 
such  cases  the  crushing  force  exerted  outside  has  been  known 
to  tear  subjacent  loops  of  intestine  in  two. 

Another  preliminary  point  to  consider  is  that  of  injury  to 
solid  viscera.  If  it  can  be  determined  that  only  a  solid  organ 
has  been  injured,  is  operation  indicated?  The  authors  answer 
the  question  in  the  negative  except  in  kidney  wounds.  Wounds 
of  the  liver  are  seldom  if  ever  benefited  by  operation.  When 
severe  they  are  fatal ;  when  not  severe  the  hemorrhage  has  usually 
ceased  at  operation.  The  same  rule  applies  to  wounds  of  the 
spleen,  except  in  those  cases  in  which  the  spleen  wound  is  caus- 
ing shock  and  then  operation  is  undertaken  with  a  view  to 
splenectomy. 

In  the  diagnosis  of  penetrating  abdominal  wounds,  speaking 
generally,  the  main  point  is  injury  to  hollow  viscera. 

The    principal    points    of    value    in  diagnosis  are:     protrusion 


ABSTRACTS  OP  WAR  SURGERY  167 

of  intestine  or  escape  of  intestinal  contents,  fluid  or  gas  through 
the  wound,  or  when  an  injury  to  a  viscus  can  be  seen  or  felt 
through  the  wound.  It  should  be  remembered  that  surgical 
emphysema  due  to  escape  of  intestinal  gas  subcutaneously,  occurs 
in  a  small  percentage  of  cases. 

If  the  intestine  protrudes  in  the  wound,  it  is  necessary  to 
determine  whether  it  is  strangulated  or  what  its  condition  may 
be.  If  in  fair  condition  and  not  strangulated  the  prognosis  is 
more  favorable. 

The  authors  mention  a  case  in  which  all  of  the  small  intes- 
tine, the  transverse  colon,  and  the  great  omentum  were  prolapsed 
through  the  wound;  the  parts  were  wrapped  in  a  khaki  shirt  in 
which  they  laid  for  eight  hours.  On  examination  the  intestines 
were  found  to  be  covered  with  mud.  After  a  cleansing  process 
under  anesthesia  the  protrusions  were  returned  to  the  abdom- 
inal cavity  and  the  patient  subsequently  made  a  good  recovery. 
When  resection  becomes  necessary  in  such  cases  the  result  is 
nearly  always  fatal.  Protruding  omentum  is  not  a  dangerous 
condition,  but  it  is  an  invariable  guide  for  operation  as  it  denotes 
visceral  injury. 

Through-and-through  shots  are  at  times  misleading.  A  shot 
entering  the  flank  and  escaping  at  the  umbilicus  may  traverse 
muscle  alone.  It  is  well  to  be  guided  by  the  anatomy  of  the 
parts  lying  between  the  wounds  of  entrance  and  exit. 

The  degree  of  dilatation  of  the  stomach  and  urinary  blad- 
der, and  the  position  of  the  diaphragm  at  the  time  of  the  injury 
are  factors  impossible  to  determine. 

The  authors  call  attention  to  a  valuable  sign,  namely,  that 
wounds  of  the  chest  alone  may  give  all  the  signs  of  an  abdominal 
injury,  and  also,  wounds  of  the  back  and  buttocks  which  give 
rise  to  retroperitoneal  hematomata  may  set  up  marked  abdominal 
rigidity  and  tenderness.  The  latter  of  these  wounds  had  been 
mentioned  by  nearly  all  observers  of  experience  in  abdominal 
wounds. 

Pain  does  not  rank  high  as  a  symptom  since  most  of  the. 
patients  have  been  dosed  with  morphia  en  route  to  the  hospital. 
Severe  pain  immediately  after  injury  lasting  a  few  minutes  is 
often  noted  in  visceral  injury. 

Vomiting  occurs  in  the  majority  of  visceral  wounds.  It  is 
common  in  stomach  wounds.  There  may  be  a  wound  of  the 
stomach  without  hematemesis.  Passage  of  flatus  following  recep- 
tion of  the  wound,  negatives  injury  to  the  large  gut,  especially 
the  descending  colon. 


168  ABSTRACTS  OF  WAR  SURGERY 

An  appearance  of  extreme  shock  betokens  grave  injury,  and 
it  is  a  better  guide  than  the  condition  of  the  pulse.  A  normal 
facial  expression  favors  the  existence  of  a  small  amount  of  injury. 

Abdominal  Signs. — 1.  Rigidity  and  absence  of  free  move- 
ment is  of  much  importance  from  a  negative  point  of  view.  Its 
absence  precludes  visceral  injury.  Its  presence,  however,  may 
be  due  to  other  causes:  chest  wounds,  retroperitoneal  hematoma, 
or  injury  to  the  abdominal  wall  alone. 

2.  Tenderness  is  of  far  more  importance.  Its  presence  at 
some  distance  from  the  wound,  especially  on  the  opposite  side 
from  the  wound,  is  almost  diagnostic  of  visceral  injury.  It 
should  be  remembered  that  tenderness  may  also  be  due  to  hem- 
orrhage in  the  peritoneum,  or  in  the  tissues  of  the  anterior  wall. 
The  latter  will  at  times  cause  extreme  tenderness. 

3.  Percussion  signs  are  fallacious,  and  little  importance  is 
attached  to  them. 

4.  Rectal  examination  is  seldom  of  value. 

5.  The  passage  of  a  catheter  may  afford  valuable  evidence 
in  cases  of  injury  to  the  bladder  and  urinary  passages. 

In  deciding  whether  to  explore  or  wait  in  a  case  which  presents 
doubt  as  to  the  presence  of  perforation,  the  deciding  factor  is 
the  patient's  condition.  When  good,  so  that  operation  presents 
little  risk  and  the  wound  is  so  recent  that  possibly  serious  vis- 
ceral injury  is  present,  it  is  far  better  to  explore. 

A  small  incision  may  be  made  in  the  middle  line  and  a  swab 
inserted  in  the  pouch  of  Douglas,  to  determine  the  presence  or 
absence  of  blood. 

Cases  in  which  there  is  little  doubt  of  the  existence  of  visceral 
perforation  should  nevertheless  be  watched  most  carefully. 
Without  visceral  lesion  they  tend  to  improve  at  once.  Such 
causes  may  remain  quiescent  for  a  long  period  and  then  take  a 
sudden  turn  for  the  worse.  A  rising  pulse-rate,  in  the  absence 
of  elevation  of  temperature  is  a  pretty  sure  indication  for 
operation. 

Contraindications  to  Operation  are  as  follows : 

1.  Apart  from  the  hopeless  condition  of  the  patient  which 
presents  itself  in  a  certain  percentage  of  cases,  the  only  other 
condition  hopeless  to  operate  is  a  complete  spinal  lesion  with 
paralysis.  In  addition  to  this  serious  condition,  these  cases  are 
difficult  to  fathom  as  to  diagnosis  since  the  spinal  lesion  will  give 
all  of  the  abdominal  signs  without  perforation  existing.  Lest 
spinal  lesions  be  overlooked,  every  patient  should  be  asked  to 
move  his  legs. 


ABSTRACTS  OF  WAR  SURGERY  169 

2.  An  abdominal  wound  complicated  by  a  chest  wound  with 
hemoptysis  or  surgical  empyema.  The  mortality  in  these  cases 
is  enormous  and  they  are  better  left  alone. 

3.  Any  other  serious  wound  forms  an  important  complica- 
tion. In  a  limb  demanding  amputation,  the  best  chance  lies 
in  doing  the  abdominal  operation  first,  leaving  the  amputation 
to  be  done  later.  If  both  operations  are  to  be  done  at  the  same 
time,  one  surgeon  should  be  detailed  to  each  operation. 

Operative  Measures. — Anesthesia. — Open  ether  by  experienced 
anesthetists,  with  or  without  chloroform  is  used  preceded  by 
atropine.  Warm  ether  apparatus  has  recently  been  used  with 
satisfaction. 

The  use  of  saline,  before,  during,  and  after  operation:  Pri- 
marily it  may  be  said  that  saline  has  been  of  no  value  in  shock, 
and  of  the  utmost  value  in  hemorrhage.  The  most  effective  way 
to  administer  it  is  intravenously.  Rectal  administration  is  of  lit- 
tle value  as  the  solution  is  not  readily  absorbed  in  severe  cases, 
and  the  danger  of  mechanically  harming  the  abdomen  should 
always  be  borne  in  mind. 

In  good  and  fair  condition  of  the  patient  subcutaneous  saline 
with  Lane's  bag  has  been  used  during  operation;  1  or  2  quarts 
with  1  c.c.  of  pituitrin  and  occasionally  one  dram  of  adrenalin 
being  infused  during  operation.  Two  cases  were  followed  by 
cellulitis  and  both  were  fatal  from  gas  gangrene  in  the  original 
wound  and  in  one  the  patient  was  infected  at  the  point  of  inocu- 
lation with  the  Bacillus  aerogenes  capsulatus. 

In  severe  cases  with  hemorrhage  it  is  always  preferable  to  use 
the  saline  intravenously,  2  quarts  or  more  to  be  administered 
with  2  drams  of  brandy,  2  drams  of  adrenalin  solution,  and  1 
c.c.  of  pituitrin.  The  practice  is  to  give  it  slowly  during  the 
course  of  the  operation  in  one  pint  portion  at  once  and  the 
remainder  later. 

Eectal  saline  in  after-treatment  by  intermittent  small  enemata, 
5  to  10  drams  (with  brandy  2  drams  to  1  quart  to  promote  ab- 
sorption) is  given  as  a  routine  measure  for  some  days.  Intra- 
venous saline  in  collapse,  when  collapse  comes  after  operation, 
is  useless  unless  the  collapse  is  due  to  secondary  hemorrhage — 
a  condition  seldom  seen  in  abdominal  cases. 

Incisions. — 1.  If  the  location  of  the  injury  is  uncertain  and 
the  small  intestine  is  almost  certainly  injured,  a  long  (6-inch) 
middle-line  incision,  extending  above  and  below  the  umbilicus,  is 
recommended.    It  should  be  made  to  one  side  of  the  linea  alba. 


170  ABSTRACTS  OF  WAR  SURGERY 

2.  When  the  injury  is  to  one  side  of  the  abdomen,  with  a  pos- 
sible colon  wound,  a  vertical  incision  through  the  rectus  has  been 
most  generally  employed,  but  a  transverse  incision  through  the 
oblique  muscles,  extending  into  the  rectus  sheath  (that  muscle 
being  pulled  inward)  may  be  employed. 

3.  Where  injury  to  the  flexure  of  the  colon  or  the  spleen  is 
suspected,  a  paracostal  incision  through  the  muscles,  and  when 
necessary  extended  in  the  same  way  into  the  rectus  sheath,  has 
been  frequently  employed.  Such  an  incision  gives  good  exposure 
and  heals  well. 

4.  Sometimes  where  a  primary  lumbar  incision  has  been  made 
in  the  case  of  a  wounded  kidney  and  the  missile  has  not  been  located, 
if  injury  to  the  peritoneum  is  suspected,  it  should  be  remembered 
that  the  peritoneum  may  be  opened  and  explored,  at  least  suf- 
ficiently to  establish  the  fact  of  presence  or  absence  of  injury 
through  the  lumbar  region. 

Except  in  cases  of  large  wounds,  the  incision  should  be  made 
•separate  from  the  original  wound.  It  should  be  closed  com- 
pletely to  obtain  first  intention  healing — drainage  tubes  are  put 
in  place  through  separate  buttonhole  incisions,  unless  the  original 
wound  can  be  utilized  for  a  drainage  tube.  Excision  of  the  skin 
about  the  original  wound  is  recommended,  likewise  cleaning  and 
draining  with  care  all  large  ramifying  wounds  in  the  abdominal 
wall  proper.  Gas  gangrene  has  been  noted  in  such  cases  and  it 
is  very  fatal. 

Great  emphasis  is  placed  on  the  value  of  utmost  care  in  closing 
the  wound  because  of  a  relatively  large  number  of  wounds  which 
have  been  known  to  give  way  as  long  as  a  fortnight  after  opera- 
tion. The  wound  should  be  closed  in  layers.  The  use  of  a  single 
row  of  deep  sutures  has  been  abandoned  except  in  most  desperate 
cases.  The  sewing  in  layers  is  done  with  chromic  catgut,  and  the 
retention  sutures  of  strong  silkworm-gut,  set  well  back,  are  removed 
on  about  the  twelfth  day. 

The  tendency  of  sutures  to  give  way  in  war  wounds  of  the 
abdomen  and  operative  wounds  in  this  region  is  due  to  the  fact 
that  the  incisions  are  usually  longer,  and  owing  to  frequent 
bronchitis  and  paralytic  distention  the  sutures  are  subject  to  a 
greater  strain  than  in  civilian  abdominal  surgery. 

In  cases  in  which  the  damaged  area  can  not  be  identified,  a 
complete  examination  of  abdominal  contents  is  in  order,  and  to 
save  time  and  lessen  shock  it  should  be  done  in  an  orderly  careful 
manner. 


ABSTRACTS  OF  WAR  SURGERY  171 

It  is  preferable  to  examine  the  injured  area  first  for  the  reason 
that  in  a  desperate  case  it  may  be  found  that,  for  example,  suture 
of  the  stomach,  colostomy,  and  a  double  resection  of  the  small 
intestine  would  be  necessary,  procedures  that  require  more 
time  than  the  patient's  condition  could  warrant  since  the  patient 
would  certainly  die  on  the  table  if  any  of  the  operations  sug- 
gested were  attempted.  In  such  cases  the  abdominal  wound  is 
closed,  the  patient  is  returned  to  the  ward  as  inoperable,  and 
morphia  is  administered  until  death  occurs. 

After  the  damaged  area  has  been  successfully  cared  for  a  rou- 
tine examination  should  next  be  undertaken.  Then  the  middle- 
line  incision  is  used,  the  surgeon  beginning  his  examination  at 
the  ileocecal  valve  or  junction,  since  wounds  are  most  frequently 
found  in  this  region.  The  ileum  is  rapidly  brought  out  in  short 
lengths  of  one  foot  and  examined,  the  uninjured  gut  being  at 
once  returned  by  the  assistant.  When  a  rent  is  discovered  the 
injured  portion  is  retained  outside,  the  position  of  the  first  rent 
or  hole  being  marked  by  a  light  clamp  or  otherwise.  The  por- 
tions retained  outside  are  kept  warm  and  moist  by  a  hot  towel, 
wet  in  saline,  being  placed  over  them.  Having  thus  examined 
the  ileum  and  jejunum,  the  transverse  colon  and  sigmoid  are  in- 
spected in  situ,  while  the  flexures,  rectum,  and  bladder,  which 
are  not  readily  visible,  should  be  inspected  by  touch.  In  some 
cases  the  missile  will  be  found  in  Douglas'  cul-de-sac,  and  this 
should  be  invariably  examined. 

Wounds  of  the  Upper  Viscera. — In  considering  the  wounds  of 
these  organs  it  is  well  to  remember  that  the  stomach  may  be 
distended  in  the  presence  of  a  considerable  hole  or  tear  through 
its  wall.  Having  found  one  orifice,  a  second  should  be  looked 
for  unless  the  missile  has  been  located  in  the  stomach. 

Liver  Wounds. — Uncomplicated  liver  wounds  do  not  require 
operation.  If  the  wound  is  small  without  hemorrhage  it  is  let 
alone.  If  large  and  bleeding,  it  should  be  packed.  Suture  is 
seldom  possible,  owing  to  the  friable  nature  of  liver  tissue. 

Spleen  Wounds. — Small  spleen  wounds  which  are  not  bleeding 
may  be  let  alone.  Usually  hemorrhage  is  taking  place,  or  it  is 
easily  excited  by  manipulation.  Suture  is  easier  than  in  liver 
tissue  and  moderate-sized  tears  are  sutured  or  packed.  Splen- 
ectomy is  resorted  to  in  serious  cases  in  which  hemorrhage  can 
not  be  controlled. 

Kidney  Wounds. — The  authors  prefer  to  deal  with  all  kidney 
wounds  through  a  lumbar  incision  since  it  is  not  always  possible 


172  ABSTRACTS  OF  WAR  SURGERY 

to  diagnose  the  extent  of  injury  otherwise.  Other  complicating 
visceral  lesions  are  treated  through  an  abdominal  incision  in  the 
usual  way.  As  to  whether  to  suture,  pack,  or  remove  the  kidney, 
the  latter  has  been  resorted  to  only  when  extensive  damage  has 
been  found,  such  as  a  tear  across  the  hilum  with  persistent 
hemorrhage.  In  cases  of  injury  where  isolated  portions  of  the 
cortex  had  been  removed  the  large  gap  was  successfully  sutured. 

Wounds  of  the  Intestines. — Small  Intestines.— Where  the  holes 
are  small,  a  purse-string  or  single  row  of  Lembert  sutures  will 
suffice.  Double  sutures  are  indicated  only  in  large  wounds  prone 
to  hemorrhage. 

Resections  give  twice  the  mortality  found  in  sutured  cases. 
If  a  resection  is  contemplated  merely  to  save  time,  it  is  safer  to 
employ  sutures.  Large  resections  recover  as  often  as  smaller 
ones. 

End-to-end  anastomosis  has  been  done  in  preference  to  the 
lateral  union.  The  latter  takes  a  quarter  of  an  hour  longer  and 
it  does  not  give  freedom  from  paralytic  distention  as  claimed 
by  some  operators.  Time  should  not  be  wasted  in  "over-elabor- 
ate stitching  in  anastomoses."  The  "leak"  at  the  mesenteric 
attachment  is    classed  by  the  authors  as  a  surgical  "bogey." 

Short-circuiting  of  the  injured  and  repaired  gut  to  avoid 
paralysis  is  not  recommended  because  postmortem  evidence  has 
shown  that  paralysis  is  general  as  a  result  of  peritonitis  and  not 
confined  to  the  injured  area. 

Large  Intestine  Wounds. — The  authors  report  that  these 
wounds  are  twice  as  fatal  as  small  gut  wounds.  Fecal  fistulse 
are  common.  Suturing  is  much  more  difficult  than  in  the  small 
intestine,  making  it  necessary  to  invariably  employ  a  double 
row.  The  use  of  antiseptic  fluid  is  recommended  after  the  first 
row  has  been  put  in  place.  A  piece  of  omentum  may  be  stitched 
over  the  repair.  When  necessary  a  separate  "gridiron"  in- 
cision in  the  flank  may  be  made  to  deal  satisfactorily  with  as- 
cending and  descending  colon  wounds.  When  possible  suture 
is  always  preferable  to  colostomy. 

The  statement  that  large  intestine  wounds  are  nearly  twice 
as  fatal  as  those  of  the  small  gut  does  not  accord  with  the  ex- 
perience in  previous  wars,  notably,  that  of  the  British  surgeons 
in  the  Anglo-Boer  War.  The  experience  in  the  Civil  War  also 
left  a  like  impression.  Otis  records  59  cases  of  spontaneous 
recovery  from  gunshot  of  the  cecum  and  ascending  colon,  the 
descending   colon,   and   sigmoid   flexure   and   a   few   instances   of 


ABSTRACTS  OF  WAR  SURGERY  173 

the  transverse  colon.  Nearly  all  the  cases  were  complicated  by 
fecal  fistula  which  closed  spontaneously  in  the  large  majority 
of  cases. 

In  forty  cases  in  the  Anglo-Boer  War,  Stevenson  fixes  the 
mortality  at  32.5  per  cent,  notwithstanding  the  fact  that  some 
of  them  had  sustained  injury  to  the  liver,  bladder,  and  kidney. 
The  same  author  fixes  the  gravity  of  gunshot  wounds  of  the  in- 
testinal tract,  irrespective  of  the  stomach,  probably  in  this 
order :  small  intestine,  transverse  colon,  ascending  colon  and 
descending  colon,  sigmoid  flexure  and  rectum. 

The  more  hopeful  outcome  of  injury  to  this  part  of  the  in- 
testine has  been  ascribed  to  the  fact  that  the  walls  of  the  gut 
are  thicker  than  those  of  the  small  intestine,  and  the  aperture 
in  them  is  partially  closed  by  the  greater  amount  of  tissue  in- 
volved in  the  perforation.  In  addition  the  fact  that  the  gut  is 
fixed  to  the  wall  of  the  abdomen  by  the  overlying  peritoneum, 
it  is  more  or  less  immobile,  extravasation  is  not  so  likely  to  occur, 
and  lastly  the  contents  of  the  large  gut  being  more  solid,  extrav- 
asation was  less  likely. 

The  difference  in  the  prognosis  of  small  intestine  and  large 
intestine  wounds  by  the  different  authors  mentioned  may  only 
be  ascribed  to  the  fact  that  the  operators  in  the  500  cases  under 
discussion  were  dealing  with  absolute  facts  as  to  location  of 
lesions,  whereas,  the  authors  who  have  collected  data  in  pre- 
vious wars  have  largely  estimated  the  lesions  by  guesswork — 
without  opening  the  abdomen,  by  estimated  perforation  of  cer- 
tain organs  in  accordance  with  the  location  of  the  wound  of  en- 
trance and  the  straight  line  between  them.  Compared  to  direct 
evidence  as  obtained  after  doing  an  abdominal  section,  the  older 
method  is  fallacious  and  the  authors  are  to  be  congratulated 
in  having  definitely  settled  an  important  point.     (Reviewer.) 

Wounds  of  the  Bladder. — Intraperitoneal  wounds  of  the  blad- 
der only  may  be  sutured  with  safety  without  draining  supra- 
pubically.  A  catheter  is  tied  in  place,  and  the  pouch  of  Douglas 
is  invariably  drained.  Extraperitoneal  bladder  wounds  through 
the  buttock  which  can  not  be  sutured  should  be  drained  thor- 
oughly through  the  original  wound  down  to  and  around  the 
bladder  wound  by  inserting  a  tube  outside  the  peritoneum. 
Most  buttock  wounds  involving  the  bladder  are  serious  unless 
proper  drainage  can  be  accomplished.  Hexamethylenamine 
should  be  given  in  all  wounds  of  the  urinary  tract  from  the  start 
until  all  danger  of  sepsis  has  passed. 


174  ABSTRACTS  OP  WAR  SURGERY 

Drainage  of  the  Abdomen  After  Operation. — Escape  of  visceral 
contents  in  every  instance  calls  for  drainage  via  Douglas' pouch. 
A  drainage  tube  in  contact  with  a  suture  in  a  large  gut  is  apt 
to  result  in  fecal  fistula  unless  it  is  promptly  removed  about 
the  second  day. 

Any  drainage  tube  has  served  its  purpose  of  forming  a  chan- 
nel in  a  very  short  time.  Its  presence  therefore  should  not  be 
unnecessarily   prolonged. 

After-treatment. — The  use  of  salines  in  after-treatment  has 
been  referred  to.  Fowler's  position  is  the  rule.  Rapid  collapse, 
secondary  shock,  in  twelve  to  twenty-four  hours  when  a  patient 
has  apparently  rallied  from  primary  shock  is  one  of  the  disap- 
pointing phenomena  noted  by  the  authors.  In  these  cases  in- 
travenous saline  is  uesless.  Strychnia  and  brandy  have  ac- 
counted for  a  second  rally  at  times. 

Laparotomy  in  war  is  followed  more  often  by  vomiting  than 
in  civilian  acute  abdominal  cases.  If  acute  distention  of  the 
stomach  is  present,  a  stomach  tube  may  cure  the  vomiting,  but 
it  should  not  be  used  in  a  condition  of  collapse. 

The  chief  danger  to  a  man  shot  in  the  abdomen  is  not  general 
peritonitis,  but  shock  and  hemorrhage.  It  is  estimated  that  if 
these  elements  of  danger  could  be  eliminated  the  mortality  in 
gunshot  wounds  of  the  abdomen  could  be  reduced  by  30  to  40 
per  cent. 

The  chief  symptoms  from  peritonitis  are  paralytic  distention, 
vomiting,  and  constipation.  As  a  phophylactic,  a  hypodermic 
of  pituitrin  followed  in  a  half -hour  by  an  enema  on  the  day  after 
operation  is  recommended  by  one  of  the  operators.  When  ob- 
structive symptoms  with  paralytic  distention  threaten  a  valu- 
able drug  is  hypodermic  eserine,  1-1000  gr.,  every  two  hours. 
Small  doses  of  calomel,  hypodermic  pituitrin,  and  turpentine 
enemata  are  also  recommended. 

When  these  measures  fail  general  peritonitis  is  usually  pres- 
ent, and  the  case  is  well  nigh  hopeless.  The  incision  can  be 
opened  up,  and  a  collection  of  pus  sought  by  separating  adhe- 
sions near  by.  In  such  cases  this  plan  has  saved  some  lives,  not 
many. 

Drainage  tubes  are  removed  early.  Gauze  packing — in  liver 
and  spleen  wounds— is  removed  about  the  fourth  day,  under 
anesthesia  or  in  stages. 

Operated  cases  are  often  disturbed  by  transport,  which  should 
be  delayed  as  much  as  possible — never  earlier  than  the  end  of 


ABSTRACTS  OF  WAR  SURGERY  175 

one  week,  however  well  the  patient  may  be.  Most  of  the  cases 
are  transported  to  the  base  between  the  tenth  day  and  a  fort- 
night. 

This  valuable  report  is  accompanied  by  a  table  which  is  full 
of  interest.  It  should  be  noted  that  among  the  500  emergency 
operations  there  were  57  laparotomies  in  which  no  injury  to 
viscera  were  found,  with  the  high  recovery  rate  of  92.9  per  cent. 
Classed  as  a  report  on  gunshot  wounds  of  the  abdomen,  with  the 
results  as  far  as  laparotomy  is  concerned,  these  should  properly 
be  excluded  from  the  table  results.  The  chances  are  that  the 
cases  would  have  recovered  without  operation.  Without  wish- 
ing to  criticise  the  judgment  of  the  operators  in  opening  the 
abdomen  for  these  injuries,  it  is  fair  to  state  that  more  of  the 
cases  would  have  recovered  without  operation.  If  these  cases 
are  put  out  of  the  reckoning,  the  recovery  rate  in  military  hospitals 
is  very  good,  in  keeping  with  the  recovery  rate  in  civil  hospitals 
for  laparotomy  after  gunshot  wounds  by  pistols  and  revolvers. 

In  Table  I  the  mortality  for  colostomy  is  very  high.  So  is 
it  for  retroperitoneal  hematoma,  gas  gangrene  of  the  abdominal 
wall,  and  wounds  of  the  lung  and  abdomen.  In  the  latter  re- 
coveries are  confined  to  solid  viscera. 

Table  II  brings  out  the  high  mortality  of  abdominal  wounds 
complicated  by  buttock  wounds.  Deaths  here  are  caused  by 
hemorrhages,  sepsis,  and  pelvic  cellulitis.  Wounds  of  the  loin 
and  flank,  and  chest  suffered  solid  viscera  involvement,  and 
among  them  also  are  included  the  majority  of  the  27  cases  in 
which  no  injury  was  found  on  operation,  hence  the  low  mor- 
tality. 

The  pulse  chart  shows  that  when  the  pulse  is  below  85  on  ad- 
mission the  prognosis  is  very  good,  and  when  it  registers  above 
110  it  is  very  bad.  It  is  noticeable  that  most  fatal  cases  with 
low  pulse-rate  are  buttock  cases. 

Conclusions. — War  wounds  of  the  abdomen  compared  with 
those  in  civil  practice  show  many  radical  differences  as  to  (1) 
gravity,  (2)  complications,  and  differences  in  (3)  characteristic 
features,  (4)  environment. 

1.  War  wounds  are  more  apt  to  be  grave  than  those  in  civil 
practice.  This  is  especially  true  of  wounds  by  shell  fragments, 
shrapnel  balls,  and  rifle  bullets,  including,  of  course,  those 
from  machine-guns  when  shots  are  inflicted  at  close  range.  In 
civil  practice,  the  shots  are  nearly  always  received  when  the  ad- 


176  ABSTRACTS  OF  WAR  SURGERY 

versaries  are  facing  each  other,  the  direction  of  the  bullet  tract 
is  usually  anteroposterior.  The  anteroposterior  shots  are  at- 
tended with  a  greater  percentage  of  recovery  than  the  oblique, 
transverse,  and  vertical  wounds  in  war. 

2.  There  are  a  number  of  complications  that  are  especially 
prone  to  appear  in  war  wounds  as  compared  to  wounds  in  civil 
hospitals. 

(a)  The  high  power  military  rifle,  which  has  a  maximum 
penetration  of  28.5  inches  in  green  oak  across  the  grain  at  50 
feet,  is  capable  of  enfilading  the  body  from  the  head  to  the 
buttock,  a  degree  of  penetration  not  possessed  by  pistols  or  re- 
volvers, the  weapons  which  usually  inflict  wounds  in  civil  com- 
munities. As  a  consequence  soldiers  often  show  wounds  through 
the  chest  and  abdomen,  or  vice  versa,  and  these  shots  are  not- 
ably attended  with  high  mortality.    . 

(b)  Infection  by  fecal  microbes,  in  the  present  world  war 
at  least,  is  a  very  fatal  complication — only  one  case  recovered 
out  of  eleven  noted  in  this  report. 

(c)  Mental  shock,  exhaustion,  and  fear  are  no  doubt  more 
frequent  complications  of  war  wounds  than  in  those  occurring 
in  civil  practice. 

(d)  Poison  by  gas  shells,  not  known  in  civil  practice,  comes 
in  this  present  war  to  add  to  the  gravity  and  complication  in 
abdominal  war  wounds. 

(e)  As  to  the  difference  in  characteristic  features  of  civil 
practice  and  war  wounds  of  the  abdomen,  in  civil  practice  the 
shots  are  delivered  by  weapons  of  much  lower  velocity.  The  pro- 
jectiles are  mostly  from  regulation  pistols  and  revolvers  of 
medium  caliber,  32,  38  and  less  often  45  caliber.  The  amount 
of  laceration  and  devitalized  tissue  is  less  than  that  of  the  mili- 
tary rifle  bullet  at  close  range,  the  shrapnel  ball,  or  shell  frag- 
ments. 

(f)  Environment  plays  a  great  part  in  peace  and  war.  In 
war  the  surgeon  is  at  the  mercy  of  the  conditions  about  him. 
For  many  reasons  it  may  be  hours  and  days  before  a  patient 
can  be  transported  to  the  hospital  for  treatment.  Adverse  con- 
ditions of  the  kind  mentioned  are  seldom  noted  in  civil  practice. 
The  surgeon  dominates  the  surroundings  and  it  is  seldom  more 
than  one  hour  before  operative  interference  can  be  undertaken 
should  it  be  deemed  necessary. 


ABSTRACTS  OP  WAR  SURGERY  177 

STAB  AND  GUNSHOT  INJURIES  OF  THE  ABDOMEN.— S. 

Basdekis,  Beitr.  v.  klin.  Chir.,  1915,  xcvi,  p.  223. 

Basdekis  reports  63  cases  of  abdominal  injury  treated  at 
the  Freiburg  Clinic,  some  of  them  injuries  in  civil  life,  others 
from  the  Balkan  War;  they  include  stab  and  gunshot  wounds, 
penetrating  and  nonpenetrating,  and  with  and  without  perfora- 
tion of  the  intestines  and  other  abdominal  viscera.  Typical 
cases  in  the  different  groups  are  described  in  detail. 

The  possibility  of  spontaneous  recovery,  the  difficulty  of  oper- 
ation under  the  proper  conditions  in  war,  and  the  severity  of  the 
operation  itself  have  caused  many  authors  to  treat  abdominal 
wounds  expectantly,  even  in  civil  life.  Among  the  most  ardent 
advocates  of  this  treatment  are  Reclus,  Berger,  and  Stimson. 
There  are  others  who  advocate  operation  in  all  cases. 

The  statistics  brought  forth  by  different  authorities  vary 
greatly.  Reclus  had  only  18  per  cent  mortality  in  114  revolver 
injuries  treated  expectantly,  while  others  with  the  same  treat- 
ment have  a  mortality  of  70  per  cent  or  more.  Siegel  collected 
several  series  of  statistics  and  found  that  the  mortality  with 
operative  and  expectant  treatment  was  about  the  same — 55  and 
51  per  cent.  But  on  working  out  the  mortality  of  376  operative 
cases  he  found  that  the  mortality  of  the  cases  operated  upon 
during  the  first  four  hours  was  15.2  per  cent,  after  five  to  eight 
hours  44.4  per  cent,  and  after  nine  to  twelve  hours  63.6  per  cent, 
and  for  all  later  laparotomies  70  per  cent.  Therefore  the  con- 
census of  opinion  in  Germany  today  is  that  the  earlier  operation 
is  performed  the  better  the  prognosis.  But  the  prognosis  in  the 
individual  case  is  and  always  will  be  doubtful. 

Most  surgeons  agree  with  Madelung  that  the  danger  in  pene- 
trating injuries  of  the  abdomen  is  over  twenty-four  hours  after 
the  injury. 

Kuttner  and  others  hold  that  all  patients  with  abdominal  in- 
juries operated  upon* on  the  field  die,  while  Filert,  Perthes,  and 
others  demand  operation  within  twelve  hours.  Von  Oettingen 
advises  that  the  following  classes  of  cases  be  operated  upon  on 
the  field:  (1)  extensive  injuries  of  the  abdominal  wall,  where 
it  is  probable  that  the  intestines  also  are  injured;  (2)  large  open- 
ings of  the  abdominal  wall  with  unincarcerated  prolapse,  or 
small  openings  with  incarcerated  prolapse;  (3)  small  gunshot 
wounds  where  there  is  no  doubt  that  there  is  intestinal  injury; 
(4)  cases  of  continuous  hemorrhage  into  the  abdominal  cavity; 


178  ABSTRACTS  OF  WAR  SURGERY 

and  (5)  when  the  picture  of  acute  peritonitis  or  sepsis  has  de- 
veloped. In  these  cases  transportation  must  be  avoided  both  be- 
fore and  after  operation.  Other  cases  must  not  be  touched  on 
the  field.  Irrigation  and  sounding  must  be  avoided.  In  the  Bul- 
garian War  the  Greeks  only  painted  the  wound  with  iodine  and 
applied  dry  aseptic  dressings.  Then  the  patients  were  trans- 
ported as  quickly  as  possible  to  a  hospital  where  they  could  be 
operated  upon  under  proper  conditions.  The  tincture  of  iodine 
gave  excellent  results.  The  wounds  treated  with  it  looked  clean 
and  showed  more  active  granulation  than  those  not  painted  with 
it.  Bornhaupt  reports  from  the  Russo-Japanese  War  that  of  13 
patients  operated  upon  on  the  battlefield  2  died,  that  is  15.4 
per  cent,  while  of  28  operated  upon  after  six  to  ten  days  thir- 
teen died,  or  46.4  per  cent. 

In  peace  the  theory  is  that .  abdominal  wounds  should  always 
be  operated  upon,  but  on  account  of  the  uncertainty  of  diagnosis 
and  the  difficulty  and  danger  of  the  operation  itself  this  does 
not  always  hold  good.  Operation  should  be  performed  if  there 
is  internal  hemorrhage,  as  all  cases  die  if  not  operated  upon. 
But  in  simple  penetrating  wounds,  without  signs  of  peritonitis, 
with  good  general  condition  and  good  pulse,  expectant  treatment 
is  best.  In  collapse  or  shock  operation  is  indicated;  both  col- 
lapse and  shock  often  change  for  the  better  under  anesthesia. 

The  mortality  of  the  penetrating  abdominal  wounds  described 
was  25  to  28  per  cent  in  cases  operated  upon  within  twelve  hours ; 
50  per  cent  on  those  operated  upon  later. 

Their  method  of  operation  was  as  follows :  Mixed  or  chloro- 
form anesthesia  was  given.  In  stab  wounds  the  cut  was  merely 
extended;  in  gunshot  wounds  an  incision  was  made  near  the  en- 
trance wound  and  a  second  perpendicular  to  it  if  necessary.  If 
the  omentum  was  prolapsed  it  was  replaced  or  ligated  with  cat- 
gut and  removed  and  the  stump  buried  in  case  it  was  soiled  or 
inflamed,  as  it  often  was.  If  the  intestine  was  prolapsed  it  was 
carefully  cleansed  and  then  replaced.  If  the  prolapsed  intestine 
was  injured  the  wound  was  first  sutured  and  then  the  intestine 
buried.    Resection  was  not  necessary  in  any  case. 

If  the  intestine  is  so  severely  injured  by  torsion  or  incarcera- 
tion in  the  abdominal  wound  that  there  is  doubt  of  its  recovery, 
two  procedures  may  be  followed:  either  an  artificial  anus  is 
formed  or  the  intestine  is  protected  with  iodoform  gauze  or  damp 
sterile  gauze  and  left  outside  the  wound  until  its  condition  im- 
proves enough  so  that  it  can  be  replaced,  or  if  gangrene  develops 
it  is  resected,  the  ends  sutured  circularly,  and  it  is  replaced. 


ABSTRACTS  OF  WAR  SURGERY  179 

For  the  toilet  of  the  abdominal  cavity  either  lukewarm  sterile 
water  was  used  or  sterile  salt  solution.  But  if  even  the  slightest 
amount  of  intestinal  contents  has  escaped  into  the  abdominal 
cavity  it  must  not  be  irrigated,  but  only  sponged  for  fear  of 
scattering  infective  material.  Many  authors  hold  that  even  ef- 
fusions of  blood  into  the  peritoneal  cavity  must  not  be  sponged 
up.  Blood,  as  well  as  intestinal  contents  must  be  thoroughly  re- 
moved, for  it  has  been  observed  that  the  peritoneum  becomes 
inflamed  much  more  easily  if  there  is  blood  in  the  abdominal 
cavity. 

To  find  injuries  of  the  intestine  or  mesenteric  vessels  the  in- 
testine must  be  examined  methodically;  that  is,  drawn  out  bit 
by  bit  and  examined  throughout  its  length  and  then  replaced. 
If  there  is  profuse  hemorrhage  or  much  intestinal  contents  in  the 
peritoneal  cavity,  eventration  may  be  necessary.  The  intestines 
in  such  cases  must  be  kept  damp  and  not  allowed  to  lie  too  long 
on  the  epidermis,  which  has  been  painted  with  iodine.  Com- 
presses moist  with  physiological  salt  solution  should  be  laid  over 
and  under  them.  If  a  mesenteric  vessel  is  injured  it  is  ligated 
at  once  with  catgut.  Sometimes,  however,  it  may  necessitate  re- 
section of  the  intestine  if  the  injured  vessel  lies  near  the  intes- 
tine and  gangrene  of  the  intestine  is  to  be  feared. 

If  the  field  of  operation  is  infected  a  strip  of  gauze,  or  better,  a 
Mikulicz  tampon,  should  be  introduced.  The  abdominal  wound 
must  not  be  entirely  closed  if  there  is  the  slightest  suspicion  of 
infection.  This  delays  healing  somewhat,  but  decreases  the  dan- 
ger of  infection.  For  suturing  the  abdominal  wall  aluminum- 
bronze  wire  is  used.  All  the  layers  of  the  abdominal  wall  except 
the  skin  are  included  and  then  the  skin  sutured  with  silk.  Some- 
times only  two  or  three  wire  sutures  are  used  and  between  them 
catgut  sutures,  which  also  include  everything  but  the  skin,  which 
is  sutured  with  silk. 

TREATMENT  OF  ABDOMINAL  INJURIES  AT  THE  FRONT. 
—Schwartz ;  THIRTY-THREE  LAPAROTOMIES  IN  CASES 
OF  ABDOMINAL  INJURY.— Bouvier  and  Caudrelier.  Bull, 
et  mem.  Soc.  de  chir.  de  Paris,  1915,  xli,  p.  1257. 

Reports  by  Schwartz  and  Bouvier  and  Caudrelier  are  reviewed 
and  discussed  by  Quenu,  who  deduces  from  them  an  argument 
in  favor  of  operative  treatment  of  abdominal  injuries  in  war. 

Schwartz  operated  upon  nine  cases,  eight  of  them  with  perfor- 


180  ABSTRACTS  OF  WAR  SURGERY 

ation  of  the  small  intestine  and  one  without  any  intestinal  lesion, 
but  with  injuries  of  the  spleen,  mesocolon,  and  great  omentum. 
There  were  two  complete  recoveries,  two  operative  recoveries 
and  five  deaths,  but  one  of  these  deaths  was  due  to  the  careless- 
ness of  the  patient,  not  to  the  operation.  He  was  getting  along 
splendidly  on  the  sixth  day,  but  that  night  got  up  to  go  to  the 
window  to  look  at  a  fire  and  the  next  day  developed  peritonitis. 
Bouvier  and  Caudrelier  report  33  cases  of  laparotomy  for  ab- 
dominal injuries.  In  all  there  were  18  deaths  and  15  recoveries, 
or  a  total  mortality  of  54.5  per  cent.  The  mortality  was  66  per 
cent  in  injuries  of  the  small  intestine,  40  per  cent  in  injuries  of 
the  large  intestine,  60  per  cent  of  only  perforating  injuries  of 
the  large  and  small  intestine  are  counted.  They  were  favored 
by  the  fact  that  they  were  very  near  the  front  and  their  patients 
had  to  be  carried  only  a  few  meters;  but  their  mortality  is  in- 
creased by  the  fact  that  they  operated  on  all  cases  as  they  came, 
no  matter  how  severe  the  injury  or  in  what  condition  of  shock 
the  patient  was  at  the  time.  They  generally  operated  through  a 
median  incision;  sometimes  they  merely  enlarged  the  existing 
wound.  When  there  was  an  evisceration  of  the  intestine  they 
sutured  or  resected  it  outside  before  opening  up  the  abdomen. 
Perforations  of  the  intestine  were  treated  by  suture;  if  there 
were  multiple  perforations  in  a  short  segment  the  intestine  was 
resected.  They  used  only  end-to-end  suture.  In  almost  all  cases 
the  peritoneum  was  irrigated  with  ether  after  the  operation;  it 
was  not  always  drained.  Every  effort  was  made  to  make  the 
operation  as  short  as  possible.  These  results  are  decidedly  in 
favor  of  operative  treatment. 

The  opinion  of  surgeons  is  very  much  divided  still  as  to  the 
question  of  operative  or  conservative  treatment  in  abdominal 
injuries. 

Quenu  quotes  a  report  of  Sencert,  who  prefers  expectant  treat- 
ment. Sencert  had  58  cases,  with  only  13  recoveries,  a  mortality 
of  77.5  per  cent,  while  Bouvier  and  Caudrelier  had  only  54.5  per 
cent  mortality  from  operative  treatment.  Moreover  Quenu  con- 
cludes from  a  study  of  Sencert 's  cases  that  not  all  of  them  were 
perforations  of  the  intestine,  so  that,  in  addition  to  having  a 
higher  mortality,  he  had  less  serious  cases.  The  published  cases 
of  various  other  authors  are  reported.  Summing  up  all  the  oper- 
ative cases,  the  average  mortality  is  62  per  cent;  while  the  aver- 


ABSTRACTS  OF  WAR  SURGERY  181 

age  mortality  of  the  conservative  cases  is  78  per  cent.  Quenu 
concludes  that  operation  is  indicated  except  in  some  cases  of  tan- 
gential shot  with  both  orifices  posterior,  indicating  that  the  in- 
testine has  not  been  perforated.  It  is  the  perforation  of  the  in- 
testine, not  of  the  peritoneum,  that  is  most  significant. 

The  indications  for  operation  depend  less  on  the  site  of  the 
wound  than  on  the  time  when  the  surgeon  gets  hold  of  the  pa- 
tient and  the  facilities  at  his  command  for  operation.  Patients 
with  abdominal  injuries  should  be  operated  upon  as  near  to  the 
trenches  as  possible,  to  avoid  jarring.  They  should  never  be  car- 
ried more  than  15  to  20  kilometers.  One  of  Sencert's  arguments 
for  conservative  treatment  is  that  the  patients  are  in  too  bad 
condition  to  be  able  to  stand  the  shock  of  operation,  but  Quenu 
reviews  the  causes  of  death  in  Bouvier  and  Caudrelier's  cases 
and  shows  that  none  of  them  died  of  shock.  One  of  the  questions 
now  to  be  solved  in  these  cases  is  the  proper  time  for  evacuation 
of  the  patients.  So  far  they  seem  to  have  been  evacuated  too 
soon,  for  quite  a  number  of  cases  are  reported  of  patients  who 
recovered  from  the  operation  but  died  as  a  result  of  the  journey 
home.  Quenu  thinks  they  should  make  the  journey  by  stages, 
traveling  only  a  few  hours  at  a  time,  preferably  by  automobile, 
and  resting  a  number  of  days  between  the  stages. 

SUTURE  OF  THE  DIAPHRAGM  FOR  GUNSHOT  WOUND 
WITH  HERNIA  OF  OMENTUM  AND  TRANSVERSE 
COLON. — 0.  Ortali.  Gazz.  d.  osp.  e.  d.  din.,  Milan,  1917, 
xxxviii,  p.  369. 

"Wounds  of  the  diaphragm  observed  in  peace  times  are  usually 
on  the  left  side  as  they  are  produced  by  cutting  or  pointed  weap- 
ons in  the  right  hand  of  the  striker.  But  war  gunshot  dia- 
phragmatic injuries  occur  on  both  sides.  One  of  the  gravest 
complications  of  such  wounds  is  the  hernia  of  abdominal  viscera. 
The  author  reports  such  a  case  in  which  omentum  and  transverse 
colon  had  herniated.  The  former  was  resected  after  a  breach 
was  made  by  resecting  a  rib  and  the  intestine  reduced  to  its  place. 
The  ruptured  diaphragm  was  sutured  with  silk.  In  this  case  the 
diagnosis  of  diaphragmatic  rupture  was  made  easy  by  the  fact 
that  a  piece  of  omentum  projected  through  the  external  wound. 


182  ABSTRACTS  OF  WAR  SURGERY 

NEW  SERIES    OF    ABDOMINAL    WOUNDS    TREATED    IN 
AUTOMOBILE  SURGICAL  AMBULANCE  No.  2.— H.  Rou- 

villois,  Guillaume-Louis,  and  Basset.     Bull,  et  mem.  Soc.  de 
chir.  de  Paris,  1917,  xliii,  p.  705. 

The  authors'  ambulance  was  stationed  about  15  kilometers 
from  the  first  line  of  trenches  and  since  their  previous  report, 
March,  1916,  they  have  observed  503  abdominal  wounds.  These 
are  divided  into:  (1)  extraperitoneal  wounds — parietal,  visceral; 
(2)  peritoneal  wounds — simple,  visceral;  (a)  univisceral,  (b) 
multivisceral. 

1.  There  were  150  extraperitoneal  wounds,  126  being  parietal 
and  24  visceral.  The  24  visceral  wounds  included  14  kidney  les- 
ions (13  recoveries  and  one  death)  and  10  wounds  of  the  bladder, 
rectum,  and  colon,  with  five  deaths. 

2.  Of  12  simple  peritoneal  wounds  without  visceral  lesion, 
three  recovered  and  nine  died.  Of  the  visceral  peritoneal  wounds 
120  gave  indications  for  laparotomy. 

The  authors  find  that  wounds  of  the  lateral  abdominal  regions 
(hypochondrial  and  iliac  fossa)  are  much  less  grave  than  those 
traversing  the  median  line  and  the  neighborhood  of  the  um- 
bilicus. 

Multiplicity  of  perforations  is  a  lesser  factor  of  gravity  than 
duration  of  the  wounds.  Some  of  the  cases  in  which  there  were 
from  six  to  ten  perforations  recovered  owing  to  very  early  in- 
tervention. 

The  first  series  of  cases  reported  by  the  authors  (March,  1916) 
showed  a  mortality  of  75  per  cent  for  univisceral  and  90.5  per 
cent  for  multivisceral  wounds.  In  this  second  series  the  corre- 
sponding figures  were  63.9  per  cent  and  66.6  per  cent.  The 
authors'  experience  has  led  them  to  abridge  the  period  of  drain- 
age in  cases  that  are  operated  upon  early,  but  in  late  oper- 
ated cases  it  must  be  prolonged  and  associated  with  rec- 
ognized methods  of  dealing  with  peritonitis  (Murphy  irrigation, 
Fowler  position). 

The  authors  report  72  thoracicoabdominal  wounds  in  a  separate 
category. 

WAR  WOUNDS  OF  THE  SPLEEN.— Fiolle.    Bull,  et  mem.  Soc. 
de  chir.  de  Paris,  1917,  xliii. 

Fiolle  reports  on  9  splenic  wounds  observed  in  his  ambulance 
since  1916.     Of  the  nine  cases,  two  were  abdominal  wounds  and 


ABSTRACTS  OF  WAR  SURGERY  183 

seven  were  abdomino-thoracic  wounds;  six  recovered  and  three 
died. 

According  to  Fiolle  spleen  injuries  are  not  so  serious  in  war  as 
has  been  represented.  Of  33  cases  which  have  been  reported  to 
the  Society  of  Surgery  of  Paris,  since  the  beginning  of  the  war 
the  mortality  is  60.6  per  cent.  The  mortality  in  isolated  splenic 
wounds,  six  deaths  in  9  cases,  is  the  same  as  in  spleen  wounds  asso- 
ciated with  other  injuries,  12  deaths  in  18  cases;  but  in  Fiolle 's  per- 
sonal statistics  the  associated  wound  cases  show  five  recoveries  in 
eight  cases. 

Fiolle  is  a  partisan  of  splenectomy  in  the  treatment  of  such 
wounds,  especially  when  there  is  rupture  or  extensive  laceration. 
Technically,  suture  is  possible  for  partial  tears  or  seton  wounds; 
but  splenectomy  is  preferable  on  account  of  the  tendency  to  sec- 
ondary hemorrhage.  Tamponade  is  applicable  only  to  wounds 
which  are  slight  as  regard  surface,  extent,  and  depth.  Generally 
speaking,  therefore,  splenectomy  is  the  operation  of  choice  in  war 
injuries  of  the  spleen. 

Regarding  the  route  of  approach,  in  the  case  of  purely  abdominal 
splenic  injuries  Fiolle  prefers  to  extend  the  classical  anterior  in- 
cision in  the  lumbar  region.  Most  splenic  wounds  are,  however, 
abdomino-thoracic  and  the  entry  wound  is  situated  low.  Duval,  who 
submitted  Fiolle 's  report,  recommends  an  incision  starting  from 
the  orifice  wound  and  descending  vertically  or  obliquely  so  as  to 
cut  the  costal  circle  perpendicularly  and  thus  become  a  left  lapa- 
rotomy directed  toward  the  anterosuperior  iliac  spine.  A  couple  of 
ribs  are  sectioned    and  removed  and  the  thorax  opened. 

Then  the  diaphragm  is  sectioned  from  its  costal  attachments  to 
the  required  depth  and  the  parietal  peritoneum  opened  as  much  as 
is  necessary.  This  procedure  gives  large  access  to  the  thorax  and 
abdomen  and  allows  the  treatment  of  pleural  or  pulmonary  lesions, 
if  there  are  such,  as  well  as  abdominal  lesions.  The  diaphragm  is 
afterwards  sutured  and  the  abdomen  and  thorax  closed. 

PROGNOSIS  AND  TREATMENT  OF  ABDOMINAL  WAR  IN- 
JURIES.—Most.  Beitr.  z.  klin.  Ckir.,  c,  1916 ;  Kriegschir.,  H. 
16,  p.  184. 

Most  gives  a  report  of  71  abdominal  wounds  observed  at  the 
front.  Of  26  rifle  bullet  wounds  12  did  not  involve  the  intestines. 
In  two  the  bladder  was  injured,  in  two  the  liver,  and  in  three  the 
pleura  and  diaphragm.    There  were  two  deaths. 


184  ABSTRACTS  OF  WAR  SURGERY 

Five  of  the  wounded  had  slight  intestinal  injuries.  Of  these 
patients,  four  died.  Of  six  cases  of  severe  gastrointestinal  injuries 
all  died.  Altogether  about  44  per  cent  of  rifle  bullet  abdominal  in- 
juries recovered. 

Of  three  abdominal  injuries  due  to  shrapnel  bullets  two  recov- 
ered. In  five  cases  of  nonpenetrative  grenade  abdominal  injuries 
only  one  recovered.  Of  four  penetrating  grenade  wounds  of  the 
abdomen  two  died. 

There  were  20  injuries  of  the  abdomen  by  grenade  with  accom- 
panying intestinal  perforations;  six  of  the  small  intestine,  nine  of 
the  large  intestine,  one  of  the  small  and  large  intestine,  one  with 
intestinal  prolapse,  and  three  with  pleural  and  diaphragm  injuries. 
Seven  cases  were  operated  upon  and  died.  The  nonoperated  cases 
all  died.  Of  seven  grenade  injuries  involving  the  chest  and  ab- 
dominal wall  without  intestinal  injury  only  two  recovered.  Both 
were  treated  conservatively. 

As  regards  the  prognosis  of  abdominal  injuries  the  author  con- 
cludes from  his  observations  that  as  a  rule  rifle  gunshot  wounds, 
as  well  as  shrapnel  injuries,  have  a  less  serious  prognosis  than  gren- 
ade and  mine  abdominal  wounds,  the  prognosis  of  which  is  ex- 
tremely serious,  and  to  a  great  extent  hopeless.  There  are  several 
matters  which  specially  influence  the  prognosis,  comprising : 

1.  Concomitant  gastrointestinal  canal  injury.  In  exceptional 
cases  small  perforations  may  heal  spontaneously,  but  more  fre- 
quently such  wounds  progress  to  a  fatal  perforation  peritonitis. 

2.  Hemorrhages,  which  as  a  rule  are  so  profuse  as  to  cause 
death. 

3.  Concomitant  injuries  of  parenchymatous  organs,  liver, 
spleen,  kidney.  Small,  smooth,  through  shots  may  heal.  Large 
lacerations  have  a  bad  prognosis. 

4.  Infection,  which  is  especially  likely  to  occur  in  grenade  and 
mine  injuries. 

5.  Shock. 

6.  The  manner  and  time  of  transportation  of  the  wounded. 

In  the  diagnosis  of  concomitant  gastrointestinal  and  organic  in- 
juries none  of  the  known  symptoms  (facies  abdominalis,  faint 
pulse,  abdominal  tension,  local  tenderness,  etc.)  are  distinctly  spe- 
cific. They  can  be  considered  of  diagnostic  value  only.  For  in- 
volvement of  the  viscera  the  trajectory  of  the  shot  must  be  con- 
sidered. 

In  infantry  gunshot  abdominal  injuries,  manifest  symptoms  of 
intestinal  involvement  is  an  indication  for  immediate  surgical  in- 


ABSTRACTS  OF  WAR  SURGERY  185 

tervention.  In  doubtful  cases  it  is  advisable  to  wait  for  a  few 
hours  and  examine  the  patient  repeatedly.  The  time  limit  is  from 
ten  to  twelve  hours  after  injury  by  rifle  shots.  If  the  condition 
of  the  patient  is  then  promising  one  can  wait  longer.  In  grenade 
injuries  or  when  there  is  persistent  hemorrhage,  Most  advises 
operation  if  there  is  any  hope  of  success. 

In  operative  procedure  the  presumption  is  that  laparotomy  can 
be  carried  out  in  an  efficient  manner;  intestinal  resection  should 
be  restricted  as  much  as  possible,  all  dirt  and  blood  removed,  with 
Mikulicz  tamponade  and  abdominal  closure  in  layers.  The  after- 
treatment  of  such  injuries  requires  very  special  care  and  observa- 
tion and  therefore  hospitals  for  such  cases  should  not  be  too  near 
the  front  where  the  nursing  and  other  conditions  can  never  be  such 
as  is  demanded  for  these  cases. 

GUNSHOT  WOUNDS  OF  THE  ABDOMEN.— Korte  and  Schmie- 
den.   Beitr.  z.  klin.  Chir.,  1916,  xcvi,  p.  509. 

Korte  and  Schmieden  reported  on  abdominal  wounds  at  the 
meeting  of  military  surgeons  at  Brussels  this  spring. 

Korte  presented  statistics  of  312  cases  and  from  his  experience 
is  an  advocate  of  conservative  treatment.  He  says  it  has  not  been 
demonstrated  that  more  lives  are  saved  by  operation  than  by  ex- 
pectant treatment.  It  is  not  always  possible  to  make  an  early 
diagnosis  as  to  whether  there  is  perforation  of  the  intestine  or  not. 
If  operation  is  to  be  performed  it  must  be  within  the  first  twelve 
hours,  the  patient  should  not  have  been  carried  far,  his  general 
condition  must  be  reasonably  good,  and  the  surgeon  must  be  skilled 
and  observe  strict  asepsis. 

Schmieden  advocates  operative  treatment.  He  says  that  spon- 
taneous recovery  in  abdominal  wounds  is  extremely  rare,  and  even 
of  those  who  apparently  recover  many  die  later  of  chronic  periton- 
itis. He  agrees  that  operation  should  be  done  within  the  first 
twelve  hours,  and  thinks  that  arrangements  should  be  made  to 
get  hold  of  as  many  cases  as  possible  within  that  time  and  treat 
them  operatively.  War  statistics,  he  says,  are  not  particularly 
reliable,  but  he  presents  a  series  of  statistics  in  which  the  per- 
centage of  recoveries  was  considerably  higher  after  operation  than 
after  expectant  treatment.  "With  armies  on  the  march,  of  course, 
it  is  difficult  to  bring  about  the  necessary  conditions  for  operation, 
but  with  the  armies  in  the  trenches  it  should  be  the  treatment  of 
choice. 


186  ABSTRACTS  OF  WAR  SURGERY 

In  the  discussion,  Friedrich  said  that  with  the  conditions  that 
prevail  at  the  eastern  battle  fields  it  is  almost  impossible  to  operate 
with  any  chance  of  success. 

Kraske  stated  his  belief  that  cases  with  and  without  intestinal 
injuries  should  be  considered  separately.  Practically  all  cases 
with  intestinal  injury  die  if  not  treated.  He  has  operated  upon 
14  cases  recently  with  six  recoveries. 

Sauerbruch  advocated  early  operation.  He  has  operated  upon 
54  cases  with  23  recoveries. 

Rehn  advocated  operation  with  the  armies  in  the  trenches,  but 
not  with  armies  on  the  march. 

Hanken  advocated  operation  on  all  cases  that  come  into  the 
surgeon's  hands  within  twelve  hours. 

NECESSITY  FOR  SYSTEMATIC  OPERATION  IN  ABDOM- 
INAL WOUNDS. — R.  Leriche.  Presse  med.,  1915,  xxiii,  p. 
221. 

Contrary  to  most  writers  on  the  subject  Leriche  is  an  earnest 
advocate  of  operation  in  abdominal  wounds.  He  says  that  the 
chief  objection  urged  against  it  is  that  it  is  impracticable  on  ac- 
count of  the  large  number  of  wounded  to  be  taken  care  of.  He  sug- 
gests the  establishment  of  a  stationary  ambulance  near  the  field, 
to  be  used  as  an  operating  room  for  abdominal  cases.  Another 
objection  is  the  high  mortality;  but  there  is  of  necessity  a  high 
mortality  in  abdominal  wounds,  whether  the  treatment  is  surgical 
or  expectant.  He  has  seen  117  cases  treated  expectantly  with  a 
mortality  of  85  per  cent,  and  other  surgeons  give  mortality  sta- 
tistics of  70  per  cent  and  up.  Leriche  thinks  this  mortality  could 
be  materially  reduced  by  operation.  He  has  operated  upon  only 
two  cases  himself,  with  recovery  in  both. 

Many  patients  with  abdominal  wounds  die  from  hemorrhage 
from  the  mesenteric  vessels,  when  no  other  organs  are  injured. 
These  cases  could  certainly  be  saved  by  suturing  the  vessels.  Many 
wounds  of  the  intestine  and  stomach  could  be  sutured  and  the  pa- 
tient saved  if  they  could  be  operated  upon  early.  Patients  with 
wounds  of  the  liver  and  spleen  certainly  stand  a  much  better 
chance  with  operation  than  without.  He  urges  that  a  systematic 
attempt  at  operative  treatment  be  made  to  see  whether  the  high 
mortality  can  not  be  reduced  in  this  way. 


ABSTRACTS  OF  WAR  SURGERY  187 

OPERATIVE  TREATMENT  OF  GUNSHOT  INJURIES  OF  THE 

INTESTINE.— Enderlen  and  Sauerbruch.     Med.  Klin.,  1915, 
xi,  p.  823. 

Enderlen  and  Sauerbruch  report  on  227  cases  of  operation  for 
abdominal  injuries,  in  211  of  which  the  intestine  was  injured. 
They  are  ardent  advocates  of  operative  treatment  in  such  in- 
juries. The  favorable  results  that  some  surgeons  have  reported 
from  conservative  treatment  are  due  to  the  fact  that  they  included 
all  cases  of  abdominal  injury,  a  large  percentage  of  them  being 
extraperitoneal. 

The  authors  had  53  cases  of  intestinal  wounds  that  were  treated 
conservatively;  46  of  them  died  in  the  field  hospital  and  three  of 
them  died  later;  only  four  were  discharged  and  sent  home  appar- 
ently well ;  even  if  they  all  lived  the  mortality  would  be  94  per 
cent.  On  the  other  hand  among  the  211  operated  cases  the  mor- 
tality was  44.4  per  cent. 

It  is  of  course  sometimes  difficult  to  make  a  diagnosis  as  to 
whether  the  intestine  is  injured  or  not,  but  if  the  abdomen  is  tense 
and  painful,  the  pulse  small  and  frequent;  if  there  is  nausea  and 
vomiting,  and  particularly  if  there  is  costal  breathing,  there  is 
probably  intraperitoneal  injury,  and  if  so  operation  is  indicated 
whether  the  intestine  is  injured  or  not.  Even  those  who  oppose 
operation  for  intestinal  wounds  admit  the  necessity  for  it  in  intra- 
abdominal hemorrhage. 

Among  the  author's  more  than  200  cases  a  mistaken  diagnosis 
of  intestinal  injury  was  made  only  eight  times,  and  none  of  those 
patients  were  injured  by  the  operation.  The  operation  is  per- 
formed in  the  same  way  as  in  civil  practice,  and  careful  after- 
treatment  is  necessary.  Salt  solution  is  given  by  the  drop  method. 
Hot  packs  and  hot-air  treatment  are  beneficial  when  possible  to 
use ;  they  stimulate  peristalsis  and  are  pleasant  to  the  patient.  The 
patients  are  given  fluid  the  first  day;  if  the  intestinal  suture  is 
firm  it  will  hold  anyway  and  if  it  is  not  abstinence  does  no  good. 
The  patient  should  not  be  transported  for  four  weeks,  but  if  it 
becomes  necessary  to  move  them  the  operated  patients  are  in  better 
condition  to  stand  it  than  those  without  operation.  The  patients 
should  be  operated  on  if  possible  within  twelve  hours  of  the  injury. 
The  results  have  been  better  the  past  few  months  than  in  the  early 
months  of  the  war.  The  authors  feel  that  operation  for  intestinal 
injuries  may  come  to  be  one  of  the  most  hopeful  fields  of  military 


188  ABSTRACTS  OF  WAR  SURGERY 

surgery,  as  those  patients  are  not  left  helpless  and  crippled  after- 
wards as  are  the  amputation  cases. 

THE  SURGICAL  AMBULANCE  AND  ABDOMINAL  WOUNDS. 

— U.  Calabrose  and  B.  Eossi.    Policlinico,  Rome,  1917,  xxiv, 
sez.  Prat.,  p.  890. 

In  Calabrose 's  ambulance  service  264  abdominal  wounds  were 
treated.  There  was  a  total  percentage  of  recovery  of  47  per  cent; 
true  operated  and  recovered  abdominal  wounds  showed  36  per 
cent. 

Eossi  treated  315  cases  and  also  had  a  total  recovery  of  about  47 
per  cent.  The  extraperitoneal  wounds  showed  82.65  per  cent  re- 
coveries. Of  the  139  penetrating  abdominal  wounds  which  were 
operated  upon  26  involved  the  parenchymatous  organs  only  and 
give  61.53  per  cent  recoveries.  There  were  110  gastrointestinal 
lesions  with  31  per  cent  recoveries.  The  author  thinks  that  only 
four  or  five  of  the  110  could  have  been  expected  to  recover  spon- 
taneously. Eeferring  to  the  high  figures  of  recovery  claimed 
by  abstentionists  he  thinks  that  many  of  the  cases  in  which  a  diag- 
nosis of  abdominal  penetrating  wound  is  made  are  really  only  su- 
perficial wounds  of  the  walls  or  of  the  neighboring  parts. 

Eossi  thinks  that  the  conduct  to  be  observed  is  immediate  inter- 
vention in  penetrating  wounds  in  which  there  is  certainty  or  a 
well-founded  suspicion  of  endoperitoneal  lesion  of  a  hollow  vis- 
cera where  there  is  hemorrhage,  flow  of  urine,  or  flow  of  bile,  since 
there  is  still  a  chance  of  saving  such  patients.  Expectant  and  med- 
ical treatment  should  be  used  in  other  cases. 

ABDOMINAL  INJURIES  IN  A  CASUALTY  CLEARING  STA- 
TION.—A.  Don.  Brit.  Med.  Jour.,  1917,  i,  p.  330. 

In  discussing  the  general  principles  of  treatment  of  war  wounds 
as  compared  with  those  in  civil  life,  the  author  states  that  he  can 
see  no  reason  for  departing  from  the  pre-war  attitude  of  explora- 
tory laparotomy  in  all  cases  of  acute  abdomen.  Even  if  a  patient 
be  in  extremis  there  is  a  better  chance  by  operation.  There  is  often 
none  after  waiting.  The  chief  danger  in  the  first  twenty-four 
hours  is  hemorrhage.  The  bowel  seems  completely  paralyzed  at 
first  by  the  blow  of  the  missile,  so  that  no  movement  takes  place 
for  at  least  twenty-four  hours,  the  injured  bowel  lying  directly 
beneath  the  wound  of  entry. 

The  indications  for  operation  are  pain  and  rigidity  of  recti, 


ABSTRACTS  OF  WAR  SURGERY  189 

marked  shock,  or  signs  of  hemorrhage.  Hemorrhage  seems  to  cause 
more  pain  and  rigidity  than  any  other  condition.  The  reason  for 
this  is    not  clear. 

Incision  is  made  with  the  bullet  wound  at  its  center.  The  injured 
portion  of  the  bowel  is  sutured  or  excised.  The  peritoneal  cavity 
is  then  washed  out  with  hot  normal  saline  solution.  Saline  is  given 
intravenously  before,  during  and  after  operation.  The  greater 
portion  of  the  cases  are  treated  in  the  horizontal  position. 

There  is  usually  little  to  guide  one  as  to  diagnosis  of  the  organ 
involved,  but  during  the  first  six  to  twelve  hours  hemorrhage  is 
nearly  always  distinguished  from  simple  perforation  because  of 
the  greater  severity  of  symptoms.  Hemorrhage  is  the  chief  danger 
in  wounds  of  the  liver.  Concussion  may  destroy  half  the  liver, 
even  when  the  bullet  has  not  hit  the  organ.  The  stomach  and 
small  intestines  were  the  organs  most  frequently  wounded  in  the 
author's  experience.  Wounds  of  the  stomach  were  sutured  in  all 
cases.  Those  of  the  intestines  were  repaired  by  circular  anasto- 
mosis with  very  low  operative  mortality.  A  detailed  report  of 
twelve  typical  cases  is  given. 


INTRAPERITONEAL  RUPTURE  OF  THE  BLADDER.— F.  Host. 

Milnchen.  med.  Wchnschr.,  1917,  lxiv,  No.  1. 

The  author  says  that  according  to  Zuckerkandl,  Rovsing,  and 
others  a  rapid  peritonitis  is  the  cause  of  death  in  the  case  of  in- 
traperitoneal bladder  rupture.  Bartels,  who  on  investigation 
found  that  the  mortality  in  the  first  three  days  after  the  acci- 
dent was  50  per  cent,  found  also  that  in  many  of  the  autopsies 
there  were  no  signs  of  grave  peritonitis,  or  even  no  peritonitis 
recorded.  This  he  has  doubted,  believing  that  peritonitis  must 
have  been  present.  Where  the  peritonitis  is  not  apparently  suf- 
ficient to  have  caused  death,  Bartels  thinks  that  this  is  due  to 
shock.  A  study  of  the  literature  shows  that  in  untreated  bladder 
ruptures  spontaneous  recovery  occurs,  but  very  rarely.  The  ma- 
jority of  patients  die  without  marked  peritonitis  within  three 
days,  from  a  cause  unknown.  Some  die  later  part  from  peri- 
tonitis and  part  from  some  undefined  cause  with  slight  peri- 
tonitis. Rost  reports  two  cases  of  this  last  kind.  The  first 
was  a  man  of  42  years.  After  a  severe  fall  no  urine  could  be 
expelled.  The  urine  and  blood  were  withdrawn  by  catheter 
but  at  low  pressure.  The  patient  died  after  four  days.  The 
vesical  lesion  was  considered  a  laceration  of  the  mucosa,  but 


190  ABSTRACTS  OF  WAR  SURGERY 

a  possible  laceration  of  the  ureters  could  not  be  excluded. 
Autopsy  showed  a  transverse  tear  in  the  bladder  posterior 
wall  near  the  neck  about  5  cm.  long.  The  catheter  had  passed 
through  this  into  the  abdominal  cavity  in  which  there  was  a 
large  quantity  of  urinous  fluid.  No  inflammatory  alterations 
of  the  peritoneum  could  be  found. 

The  second  case  of  rupture  was  also  found  at  autopsy  and 
was  not  suspected  and  there  was  an  irregular  intraperitoneal 
tear  of  about  1.5  cm.    There  was  a  slight  degree  of  peritonitis. 

EARLY  TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE 
ALIMENTARY  CANAL.— C.  "Wallace.  Lancet,  London,  1915, 
clxxxix,  p.  1336. 

In  trying  to  arrive  at  the  relative  frequency  of  abdominal 
wounds  the  following  data  were  obtained  in  a  certain  number 
of  casualty  clearing  stations : 

1.  1.88  per  cent  of  all  wounds, 

2.  1.5     per  cent  of  all  wounds, 

3.  0.75  per  cent  of  all  wounds, 

4.  0.62  per  cent  of  all  wounds. 

The  statistics  from  9  field  ambulances  and  7  casualty  clear- 
ing stations  for  a  period  of  six  months  showed  the  following 
results:  Percentage  of  abdominal  wounds  to  total  wounds, 
field  ambulances,  1.92  per  cent,  casualty  clearing  stations,  0.72 
per  cent.  The  difference  is  attributed  to  the  greater  mortality 
in  field  ambulances. 

In  1,098  abdominal  wounds  in  9  field  ambulances  during  a 
period  of  six  months  the  mortality  was  30.33  per  cent.  In  131 
cases  of  perforating  abdominal  wounds  in  the  same  period  from 
6  casualty  clearing  stations  the  mortality  was  58.49  per  cent. 

As  to  the  influence  of  position  of  the  wound  and  direction  of  the 
missile  on  the  probable  nature  of  the  injury,  it  is  noted  that  in 
the  region  above  the  pyloric  plane  are  found  the  least  serious 
among  abdominal  wounds.  Side-to-side  wounds,  especially  if 
they  are  located  far  back,  are  very  serious.  Vertical  wounds, 
from  above  downward,  are  also  serious. 

Midline  anteroposterior  wounds  are  seldom  seen,  due  to 
the  vena  cava  and  aorta  occupying  this  line,  wounding  of  which 
causes  immediate  death.  The  liver  is  most  apt  to  be  hit  on 
the  right  side  of  this  line,  and  the  stomach  occupies  the  space 


ABSTRACTS  OP  WAR  SURGERY  191 

on  the   left  side.     Stomach   wounds   usually  occupy   both   sur- 
faces of  the  organ. 

On  the  right  side  the  liver  will  be  hit;  the  cardia  and  greater 
curvature  of  the  stomach  will  be  perforated  on  the  left  side. 
The  kidneys  will  be  perforated  by  shots  traversing  the  lateral 
lines  of  the  body  including  the  spleen  and  splenic  flexure  on 
the  left  side.  Uncomplicated  liver  and  stomach  wounds  are 
as  favorable  as  similar  wounds  in  the  epigastric  region. 

Oblique  epigastric  and  hypochondriac  wounds  are  necessar- 
ily more  serious  and  they  become  more  so  as  they  become  more 
oblique.  The  character  of  the  liver  wounds  in  these  shots  is 
marked  by  greater  laceration  and  greater  tendency  to  hemor- 
rhage, and  the  stomach  wounds  are  marked  by  a  long  slit  or 
double  opening  when  the  axis  of  the  flight  of  the  bullet  be- 
comes parallel  to  the  anterior  wall,  in  which  case  extravasation 
is  prone  to  occur.  The  liver  and  stomach  wounds  are  apt  to 
be  complicated  by  spleen,  kidney,  and  splenic  flexure  involve- 
ment. 

Vertical  epigastric  or  hypochondriac  wounds  are  nearly  all 
inclined  downward,  though  they  may  be  almost  vertical,  the 
entrance  and  exit  wounds  being  located  on  the  front  of  the 
body.  In  such  cases  the  wounds  of  the  liver  and  stomach  are 
complicated  by  involvement  of  the  colon  or  small  intestine. 
Vertical  wounds  on  the  lateral  surface  appear  as  thoracic 
wounds  when  they  show  no  exit  wounds.  Those  on  the  right 
side  are  not  so  dangerous  since  they  traverse  only  liver  sub- 
stance ;  those  on  the  left  are  more  dangerous  as  they  are  apt 
to  implicate  the  spleen,  stomach,  or  colon.  These  at  first  point 
entirely  to  thoracic  injury. 

Posterior  and  lateral  wounds  of  the  hypochondriac  region 
are  apt  to  be  single  entry  wounds.  Those  from  side  to  side 
are  seldom  seen,  owing  to  their  great  fatality.  They  involve 
the  liver,  spleen,  stomach,  pancreas,  and  even  the  great  ves- 
sels. 

Wounds  between  the  axillary  lines  often  exhibit  omentum 
protruded  through  the  ribs.  They  are  more  serious  on  the 
left  side  from  the  spleen,  kidney,  and  splenic  flexure  involve- 
ments. These  wounds  are  often  caused  by  shrapnel  or  shell 
fragments.  Access  to  this  region  is  not  easy;  the  wounds  are 
therefore  difficult  and  unsatisfactory  to  treat. 

"Wounds  between  the  transpyloric  and  intertubercular  planes 
are  very  serious.    Above  the  umbilicus  they  are  like  those  above 


192  ABSTRACTS  OF  WAR  SURGERY 

the  transpyloric   plane,   and  below  the   umbilicus  the   small   in 
testine  is  involved. 

Anteroposterior  shots  in  the  midline  are  seldom  met  with.  On 
either  side,  in  the  upper  part  of  this  region  the  colon  is  in- 
volved and  injuries  to  it  are  easily  dealt  with.  Lower  down, 
near  the  midline,  the  wounds  are  grave  as  they  involve  the 
small  intestine.  Toward  the  sides  in  the  lumbar  regions,  we 
find  wounds  of  the  ascending  or  descending  colon.  If  the 
peritoneal  surface  alone  is  involved  the  danger  is  not  so  great 
unless  the  wound  in  the  wall  is  large.  Wounds  in  the  left 
lumbar  region  are  very  much  more  dangerous  as  the  coils  of 
jejunum  overlie  the  great  bowel.  In  flank  wounds  the  colon 
and  peritoneum  may  both  escape  owing  to  the  thickness  of  the 
abdominal  wall. 

Wounds  entering  the  back  in  this  region  are  apt  to  plow 
up  the  retroperitoneal  tissue  by  mechanical  violence  or  by  sub- 
sequent hematoma,  and  they  are  consequently  more  fatal  than 
anteroposterior  wounds.  Single  entry  wounds  of  the  loin  often 
injure  the  retroperitoneal  tissue  and  pass  into  the  colon  tissue. 
Shell  fragments  and  wounds  in  this  location  are  grave ;  they  cause 
a  large  opening  with  escape  of  feces  but  free  drainage  and  the 
fact  that  the  traumatism  is  in  plain  view  assists  in  the  steps 
to  be  taken.  This  is  seldom  the  case  in  wounds  caused  by 
smaller  projectiles  where  leaks  in  the  retroperitoneal  tissue 
may  occur  which  may  cause  death  before  sufficient  drainage  is 
provided. 

Side-to-side  wounds  are  very  apt  to  be  fatal.  If  the  small  and 
large  intestines  are  both  involved,  the  spine  or  great  vessels  are 
injured  since  the  vertical  colons  are  set  well  back.  For  this 
reason  side-to-side  wounds  which  involve  the  small  intestine 
alone  seldom  include  the  colon.  The  amount  of  damage  done 
varies.  In  some  cases  the  gut  is  lacerated  and  cut  across,  the 
transverse  colon  and  central  portion  of  the  stomach  may  be  all 
but  completely  cut  by  one  bullet.  There  may  be  only  clean 
cut  perforations  or  the  peritoneum  only  may  be  penetrated. 

All  wounds  below  the  intertubercular  plane  are  very  serious. 
They  include  shots  through  the  hips,  thighs,  and  buttocks. 

Anteroposterior  wounds  in  the  hypogastric  region  are  very 
serious,  especially  when  compared  to  anteroposterior  shots  in 
the  epigastric  region.  Midline  wounds  are  fairly  frequent; 
the  bladder  is  not  often  implicated  unless  it  is  full  at  the  time 
of  injury;  the  pelvic  colon  and  rectum  may  be  involved. 


ABSTRACTS  OF  WAR  SURGERY  193 

In  the  iliac  regions  the  iliac  colon  and  cecum  may  be  impli- 
cated. 

Small  intestinal  wounds  are  nearly  always  multiple,  the  bladder 
and  rectum  wounds  may  be  intra-  and  extraperitoneal. 

In  vertical  wounds  the  wound  of  entry  is  often  through  the 
buttock,  perineum,  or  thigh,  and  the  iliac  vessels  may  be  in- 
volved. The  perineal  wounds  are  often  overlooked,  but  pain 
in  the  abdomen  is  often  present  and  should  lead  to  suspicion 
of  internal  injury.  The  fatality  in  these  cases  is  due  mostly 
to  hemorrhage  from  the  iliac  vessels  and  the  fact  that  perineal 
wounds  are  often  overlooked.  Wounds  of  the  rectum  are 
quickly  fatal  from  peritonitis. 

The  possibility  of  a  bullet  traversing  the  peritoneal  cavity 
without  injury  to  the  viscera  is  discussed  in  an  interesting  way. 
The  author  gives  a  chart  which  shows  a  number  of  cases  in 
which  the  abdomen  was  opened  for  exploratory  laparotomy 
and  in  which  no  hollow  viscera  were  opened  although  the  en- 
trance and  exit  wounds  clearly  pointed  to  such  an  injury.  In 
these  operations  tears  of  the  peritoneal  coats  of  the  hollow 
viscera,  stomach,  or  intestine,  were  not  infrequently  seen,  a 
fact  which  would  indicate  that  even  a  modern  bullet  can  push 
aside  the  visceral  wall  without  perforating  it.  Such  cases  are 
believed  to  account  in  a  certain  proportion  of  cases  for  com- 
plications like   fecal   fistula  and  intraperitoneal   abscess. 

Determination  of  peritoneal  involvement  to  make  sure  that 
the  wound  is  penetrating  is  frequently  difficult.  This  is  es- 
pecially true  when  there  is  no  wound  of  exit.  Symptoms  of 
shock,  hemorrhage,  rigidity,  peritonitis,  and  rapid  pulse  point 
to  penetration,  but  these  are  not  always  present. 

Below  the  transpyloric  plane  an  entrance  wound  on  the  right 
of  the  midline  and  the  exit  wound  anterior  to  the  right  lateral 
line  of  the  body  is  apt  to  be  nonpenetrating.  On  the  other 
hand  above  the  transpyloric  line  such  a  wound  is  almost  sure 
to  be  penetrating.  In  the  longitudinal  direction  an  entrance 
wound  near  the  costal  margin  with  an  exit  wound  above  the 
groin  points  to  penetration. 

In  the  case  of  single  entry  wounds  the  symptoms  alone  indi- 
cate penetration  or  nonexistance  of  peritoneal  involvement. 

A  vertical  wound  entering  from  the  thorax  may  give  no  sign 
for  some  time.  A  vertical  wound  entering  from  the  buttock 
is  apt  to  be  attended  with  pain  at  the  time  of  injury. 

Absence  of  liver  dullness  is  no  criterion  of  visceral  penetra- 
tion.    Abdominal  injury  from  a  bomb  explosion  which  exhibits 


194  ABSTRACTS  OF  WAR  SURGERY 

multiple  small  wounds  may  be  attended  with  doubt  as  to  the 
existence  of  penetration.  Rather  than  explore  one  or  two  of 
these  wounds  for  the  purpose  of  diagnosis  it  is  best  to  make 
an  abdominal  incision,  and  to  be  guided  in  accordance  with 
the  findings.  The  author  has  found  as  many  as  14  perforations 
in  the  small  gut  from  small  fragments  issuing  from  one  bomb. 

Symptoms  of  peritoneal  involvement  are  generally:  (1)  rigid- 
ity of  the  belly  wall;  (2)  rapid  pulse;  (3)  indications  of 
hemorrhage;  and  (4)  absence  of  liver  dullness. 

Eigidity  is  seldom  absent  after  4  to  5  hours;  the  same  is 
true  of  the  pulse-rate.  Local  trauma  without  penetration  may 
show  rigidity  but  the  pulse-rate  may  not  rise. 

Symptoms  of  hemorrhage  are  hard  to  distinguish  from  shock. 
There  is  blanching  and  rapid  pulse  in  both.  In  the  case  of 
hemorrhage  restlessness  is  seldom  seen.  The  same  is  true  of 
air  hunger  and  failure  of  sight.  The  amount  of  hemorrhage  is 
generally  very  great  before  dullness  can  be  of  significance  as 
a  symptom. 

Retroperitoneal  hemorrhage  causes  decided  abdominal  rigid- 
ity and  well  marked  shock. 

The  effect  that  shock,  hemorrhage,  peritonitis,  and  septic  in- 
fection of  the  retroperitoneal  tissue  have  in  causing  death  is 
shown  as  follows : 

1.  The  amount  of  shock  is  usually  severe  and  it  may  be 
absent  or  nearly  so  for  a  number  of  hours.  What  actually 
causes  shock  is  undecided.  Usually  it  is  proportional  to  the 
extent  of  the  injury;  but  profound  shock  may  be  present  with 
a  limited  lesion  or  may  be  clearly  absent  in  an  extensive  one. 

2.  Hemorrhage  is  probably  the  most  frequent  cause  of  death. 
Its  source  is  from  (1)  great  vessels,  (2)  the  mesentery,  (3) 
the  omentum,  (4)  the  abdominal  wall  and  retroperitoneal  tis- 
sue, and  (5)  the  solid  viscera.  Of  these,  the  mesenteric  are  the 
vessels  most  frequently  found  bleeding  when  the  abdomen  is 
opened. 

3.  Peritonitis  is  the  common  cause  of  death,  sometime  after 
injury.  It  may  be  fatal  within  twenty-four  hours  if  the  infec- 
tion comes  from  a  wound  of  the  rectum. 

4.  Infection  of  the  retroperitoneal  tissue  may  come  from  the 
bowel  or  the  aerogenes  capsulatus.  In  the  case  of  the  former 
the  infection  usually  comes  from  wounds  of  the  colon. 

Trench  fighting  has  permitted  the  establishment  of  well-ap- 
pointed operating  centers  close  to  the  fighting  line,  so  that  cases 
of  abdominal  wounds  can  be  collected  rapidly  into  an  operat- 


ABSTRACTS  OF  WAR  SURGERY  195 

ing  room  under  the  management  of  expert  abdominal  surgeons. 
This  fact  has  materially  changed  the  management  of  abdominal 
wounds  in  military  surgery.  The  conditions  on  the  western 
front  so  far  as  this  class  of  wounds  is  concerned  approximate 
those  in  civil  practice  in  well-appointed  hospitals  in  which  the 
surgeons  control  all  the  environments.  The  rule  of  operating 
early  has  become  the  vogue  at  the  casualty  stations  on  the 
western  front.  The  rest-treatment  supplemented  by  morphia, 
which  obtained  in  the  Spanish-American,  Anglo-Boer,  Russo- 
Japanese,  and  other  recent  wars  in  which  the  mobile  armies 
were  fighting  in  the  open,  is  no  longer  favored. 

In  caring  for  patients  before  operation  morphine  is  at  once 
employed  for  the  relief  of  pain  and  to  allay  anxiety  during 
transport  to  the  casualty  station.  Fluids  should  be  adminis- 
tered in  very  moderate  quantities.  On  reaching  the  operating 
hospital  the  patient  is  put  to  bed,  and  is  given  subcutaneous 
saline  for  the  treatment  of  shock.  If  no  improvement  takes 
place  hemorrhage  is  probably  present  and  operation  should  be 
undertaken.  If  hemorrhage  is  found  the  chances  of  saving  the 
patient's  life  are  good. 

At  operation  a  paramedian  incision  is  employed  and  it  should 
be  used  in  all  cases  unless  it  is  contraindicated.  A  long  incision 
saves  time  and  shock.  The  first  indication  is  to  arrest  hemor- 
rhage and  the  second  to  systematically  examine  for  wounds  of 
the  hollow  viscera. 

In  resection  circular  enterorrhaphy  is  better  than  lateral  anasto- 
mosis. Lesions  of  the  small  bowel  must  be  dealt  with  first  and 
the  colon  next. 

The  author  gives  no  figures  on  the  results  of  the  cases  oper- 
ated upon  but  he  promises  to  do  so  when  a  series  of  cases  has 
been  collected  for  six  months.  He  states  that  the  results  se- 
cured so  far  indicate  positively  that  the  mortality  at  the  cas- 
ualty clearing  stations  has  been  very  much  reduced  by  early 
operative   interference. 

FOREIGN  BODIES  IN  THE  BLADDER  RESULTING  FROM 
GUNSHOT  WOUNDS.— G.  G.  Turner.  Lancet,  London, 
1916,  cxc,  p.  958. 

The  author  cites  three  cases  of  wounded  soldiers  in  the  pres- 
ent European  War,  in  which  the  foreign  body  had  presumably 
lodged  in  the  bladder  at  the  time  of  the  casualty,  for  in  each 
instance  there  was  some  urinary  trouble  from  the  outset.     The 


196  ABSTRACTS  OF  WAR  SURGERY 

lodgment  of  a  missile  in  the  bladder  is  an  event  well  recog- 
nized in  all  campaigns.  In  most  museums  there  are  specimens 
of  calculi  in  which  the  nucleus  is  formed  by  some  type  of  bul- 
let. In  the  x-ray  investigation  of  such  cases  plates  should  be 
made  with  the  patient  in  various  positions  and  with  the  blad- 
der empty  and  distended.  Marked  alteration  in  the  position 
of  the  shadow  will  then  be  a  guide  as  to  the  freedom  of  the 
foreign  body  in  the  viscus.  A  routine  cystoscopic  examination 
ought  also  to  be  carried  out,  for  there  may  be  some  nonmetallic 
foreign  body  in  addition  to  that  shown  by  the  x-rays,  or  the 
foreign  body  may  be  entirely  nonmetallic,  and  a  negative  x-ray 
examination  is  therefore  not  enough  to  establish  the  diagnosis. 
It  is  interesting  to  observe  how  the  wound  in  the  bladder 
spontaneously  closes.  Small  foreign  bodies  always  tend  to  es- 
cape with  the  urine,  but  those  that  can  not  negotiate  the  urethra 
may  sometimes  be  safely  removed  in  the  eye  of  an  evacuating 
catheter.  Legueu,  using  a  specially  modified  lithotrite,  has  re- 
moved rifle  and  machine-gun  bullets  per  urethram  rapidly  and 
without  general  anesthesia.  For  shrapnel  bullets,  large  or 
ragged  fragments  of  shell,  or  incrusted  foreign  bodies,  the 
author  considers  the  suprapubic  route  the  method  of  choice, 
and  he  believes  it  will  certainly  be  the  safest  in  the  hands  of 
those  without  special  training. 

TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE  BLADDER. 

— V.  Saviozzi.     Clin,  chir.,  1916,  xxvi,  p.  324. 

Saviozzi  reports  two  cases  of  gunshot  injuries  of  the  bladder 
treated  by  suprapubic  cystotomy  and  tamponing  the  bladder 
opening  with  favorable  result.  In  one  of  the  cases  there  was 
found  located  in  the  bladder  a  bullet  as  well  as  some  spicules 
from  the  fractured  innominate  bone. 

Gunshot  wounds  of  the  bladder  are  more  frequent  than  any 
other  kind  of  bladder  wounds.  Bartels  collected  285  such  cases, 
but  it  is  only  very  rarely  that,  as  in  one  of  these  cases,  a 
bony  fragment  is  carried  into  the  bladder  by  the  projectile. 
Bladder  injuries  of  this  kind  are  classed  either  as  intra-  or 
extraperitoneal.  In  the  intraperitoneal  variety  the  prognosis 
according  to  most  writers  is  absolutely  fatal.  Although  this 
prognostic  conception  seems  rather  exaggerated  to  the  author,  yet 
in  the  statistics  of  152  intraperitoneal  cases,  collected  by  Rivington, 
there  was  no  recovery,  nor  was  there  a  recovery  in  any  of  the  cases 
reported  by  Bartels. 


ABSTRACTS  OF  WAR  SURGERY  197 

Extraperitoneal  injuries  have,  however,  a  more  favorable 
prognosis,  but  it  is  difficult  to  determine  whether  the  injury  is 
intra-  or  extraperitoneal  as  the  early  symptoms  in  both  are 
identical. 

Regarding  treatment,  the  prime  necessity  is  to  arrest  hemor- 
rhage and  assure  the  flow  of  urine.  Some  recommend  the 
sonde  a  demeure  in  extraperitoneal  injuries,  others  recommended 
suture  of  the  bladder  and  a  laparotomy  in  either  variety  of 
injury. 

As  to  the  treatment  adopted  by  the  author,  i.  e.,  cystotomy 
with  tamponade  of  the  bladder  (with  laparotomy  also  in  the 
first  case),  he  thinks  that  the  brilliant  results  obtained  author- 
ize him  to  strongly  recommend  this  procedure  because  it  is 
rapid,  safe,  and  in  serious  cases  can  even  be  carried  out  under 
local  anesthesia.  In  these  cases  suture  of  the  bladder  was 
technically  impossible  and  in  gunshot  wounds  accompanied  by 
a  perivesicular  hemorrhage  the  difficulties  of  suturing  are  such 
as  to  favor  the  simpler  and  equally  safe  method  adopted  by  him. 

INTRAPERITONEAL  BLADDER  WOUNDS.— H.  Brin.     Bull. 
et  mem.  Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  1086. 

Brin  does  not  think  that  intraperitoneal  lesions  of  the  blad- 
der are  very  grave;  generally  it  is  easier  to  treat  them  than 
the  generality  of  visceral  lesions.  In  the  scale  of  gravity  they 
may  be  classed:  (1)  The  least  grave  are  evidently  those  which 
attack  the  anterior  surface  under  the  peritoneal  cul-de-sac. 
(2)  Then  come  intraperitoneal  lesions.  (3)  The  most  serious 
are  those  involving  the  fundus  of  the  bladder  or  the  lower  part 
of  the  lateral  surfaces,  because  direct  treatment  is  more  deli- 
cate and  especially  because  they  are  often  associated  with  rec- 
tal or  osseous  lesions  which  lead  to  general  infection. 

Although  there  are  some  spontaneous  recoveries  the  treat- 
ment of  bladder  injuries  is  entirely  surgical.  The  technic  varies 
according  to  the  nature  of  the  injury. 

1.  For  extraperitoneal  injuries  of  the  anterior  surface,  if 
high  and  if  after  regularization  they  can  be  correctly  sutured, 
the  practice  should  be  suture  with  a  sonde  a  demeure.  If  the  lesion 
is  in  the  vicinity  of  the  neck,  suture  should  not  be  tried.  The 
practice  should  be  cystostomy  as  high  as  possible  and  a  sound 
placed  after  an  interval. 

2.  For  intraperitoneal  injuries  if  in  the  apex  or  in  the  posterior 
face  region,  intervention  should  be  by  resection  of  the  edges, 


198  ABSTRACTS  OF  WAR  SURGERY 

suturing  in  two  places  with  fine  catgut,  and  placing  a 
sonde  a  demeure.  The  Douglas  sac  should  be  closed  by  a  row  of 
sutures,  thus  carefully  isolating  the  wound  from  the  rest  of 
the  abdominal  cavity,  followed  by  cystostomy. 

As  wounds  of  the  fundus  are  usually  produced  by  perineal 
projectiles,  they  necessitate  a  lateral  perineotomy  or  even 
transverse  as  wide  as  possible  so  that  a  loose  tamponade  in 
contact  with  the  bladder  wall  may  be  made. 

THE  TREATMENT  OF  SIMULTANEOUS  LESIONS  OF  THE 
RECTUM  AND  BLADDER.— F.  Crosti.  Biforma  med.,  1917, 
xxxiii,  p.  604. 

The  author  has  collected  45  cases  of  rectal  lesions  treated  at 
the  war  hospitals.  Among  these  14  showed  a  concomitant  lesion 
of  the  bladder,  2  of  the  posterior  urethra.  One  of  the  latter 
showed  a  perforation  of  the  left  prostatic  lobe. 

In  9  cases  there  was  urinary  infiltration;  in  3  a  diffuse 
phlegmon  of  the  pelvirectal  space.  In  the  cases  with  urethral 
lesions  there  was  ischuria;  in  the  other  cases  there  was  more 
or  less  abundant  flow  of  urine  mixed  with  particles  of  feces, 
although  the  orifice  of  issue  was  situated  high  in  several  of 
the  cases.     In  the  14  bladder  cases  there  were  five  deaths. 

With  regard  to  the  treatment  of  these  cases  the  usual  prac- 
tice is  to  prevent  infiltration  and  stagnation  of  urine  in  the 
tissues  with  consequent  infection  through  the  rectal  opening. 

Although  in  some  cases  recovery  may  be  obtained  by  simple  ap- 
plications of  a  sonde  a  demeure  and  without  treatment  of  the  rec- 
tal lesions,  in  others  an  intervention  must  be  made  with  cystoto- 
my and  colotomy  to  draw  off  the  feces.  The  first  indication  is 
to  widely  open  up  all  along  the  tract  of  the  projectile.  If  there 
is  a  bony  barrier  opposed  to  reaching  to  the  urofecal  collec- 
tion it  will  be  necessary  to  use  a  transversal  perineotomy  with 
the  Albarran  or  Jung  incision.  In  order  to  avoid  the  constant 
danger  of  infection,  the  formation  of  a  permanent  anus  contra 
natura  for  the  complete  deviation  of  the  feces  is  recommended. 
In  the  majority  of  cases  after  the  perineotomy  a  simple  sonde  a 
demeure  will  suffice  to  cure  the  bladder  lesions  and  recourse  to 
cystotomy  will  be  rare. 

Deviation  by  colostomy  was  executed  by  the  author  6  times 
with  only  1  death. 


ABSTRACTS  OF  WAR  SURGERY  199 

SURGICAL    TREATMENT    OF    WAR    WOUNDS    OF    THE 
ABDOMEN.— Rev.  of  War  Surg,  and  Med.,  April,   1918,  i, 

No.  2. 

As  the  war  has  progressed,  the  only  evolution  that  has  taken 
place  in  ideas  regarding  abdominal  wounds  has  been  in  the 
direction  of  improving  facilities  for  the  early  operative  care 
of  this  type  of  injury.  It  has  always  been  difficult  for  the 
civil  surgeon  to  grasp  the  dictum  that  penetrating  war  wounds 
of  the  abdomen  were  to  be  treated  expectantly.  Col.  Cuthbert 
Wallace,  in  three  Lettsomian  lectures  on  the  subject  of  war 
surgery  of  the  abdomen  (Lancet,  1917,  i,  pp.  561,  597,  637),  traces 
the  explosion  of  this  fallacy,  and  then  furnishes  the  most  il- 
luminating exposition  of  war  wounds  of  the  abdomen  that  has 
yet  appeared. 

The  opinion  that  the  operative  treatment  of  abdominal  wounds 
was  not  to  be  undertaken  under  war  conditions  was  partly  due, 
according  to  Wallace,  to  want  of  success,  as  in  the  Spanish- 
American  War,  and  partly  to  the  fact  that  many  military  sur- 
geons were  opposed  to  extensive  operating  anywhere  near  the 
firing  line.  As  abdominal  surgery,  to  be  successful,  must  be 
done  at  once,  it  is  obvious,  he  says,  that  it  could  not  be  under- 
taken with  success  where  all  operations  had  to  be  postponed 
to  a  late  period.  When  the  South  African  War  broke  out  the 
expectant  treatment  was  the  orthodox  one.  Many  civil  sur- 
geons hoped  to  prove  it  wrong,  and  an  appeal  was  issued  by 
the  Surgeon-General  recommending  the  early  operative  treat- 
ment of  abdominal  penetrating  wounds.  Opposing  opinion, 
however,  was  brought  to  bear,  on  the  basis  that  expectant  treat- 
ment was  in  itself  the  right  procedure,  and  that  it  was  the 
best  that  could  be  done  in  war.  The  South  African  campaign 
ended  with  surgical  opinion  opposed  to  early  operation  for 
penetrating  abdominal  wounds.  This  opinion  seems  to  have 
been  strengthened  by  succeeding  wars — the  French  War  in 
Morocco,  the  Balkan  War,  and  the  Russo-Japanese  War. 

Shortly  after  the  beginning  of  the  present  war,  according 
to  Wallace,  Souttar  commenced  early  operation  in  the  Belgian 
Army.  Owen  Richards  was  the  first  to  publish  results  of  opera- 
tive treatment  in  the  British  Army  (Brit.  Med.  Jour.,  Aug.  7, 
1915).  The  first  case  of  operation  was  performed  on  January 
28,  1915,  and  the  first  successful  case,  that  of  a  resection  of 
2y2  feet  of  the  small  intestine,  was  performed  on  March  18, 
1915,  36  hours  after  receipt  of  the  injury. 

Holding  the  opinion  that  early  operation  was  indicated,  Wal- 


200  ABSTRACTS  OF  WAR  SURGERY 

lace  commenced  operating  and  making  postmortem  examina- 
tions, and  soon  convinced  himself  that  abdominal  injuries  were, 
as  a  rule,  of  such  a  nature  that  recovery  without  operation 
must  be  a  very  rare  event.  It  was  also  found  that  hemorrhage 
was  a  chief  cause  of  early  death,  and  that  bullets  produced 
very  extensive  injuries — two  very  important  points.  The  re- 
establishment  that  hemorrhage  was  the  chief  cause  of  early 
death  was  of  great  importance,  as  it  showed  that  only  by  rapid 
evacuation  could  one  hope  to  combat  such  a  condition. 

Wallace  bases  his  communication  on  all  abdominal  wounds, 
which  reached  an  operating  hospital  from  a  certain  sector  of 
the  line  over  a  period  of  18  months.  In  arriving  at  a  conclu- 
sion of  the  mortality  of  abdominal  wounds  and  what  can  be 
done  for  them  by  operative  treatment  it  is  necessary,  accord- 
ing to  Wallace,  to  take  a  sector  of  the  line  and  to  include  all 
the  cases,  no  matter  at  what  hospital  they  are  treated.  Re- 
sults differ  in  different  hospitals,  more  or  less  depending  upon 
their  distance  from  the  firing  line ;  they  will  also  differ  accord- 
ing to  the  nature  of  the  fighting.  It  is  necessary  not  only  to 
reckon  the  operative  mortality  but  to  bring  into  account  all 
cases  which  arrive  too  bad  for  operation.  This  has  been  done 
in  the  present  series.  The  statistics  were  collected  from  the 
records  of  all  the  hospitals  called  upon  to  treat  abdominal 
cases,  each  institution  having  been  provided  with  a  book  in 
which  certain  headings  were  written  down  and  filled  in  by  the 
medical  officers  at  the  time  of  operation. 

The  following  figures  show  the  differences  in  results  which 
may  be  obtained  in  different  hospitals  under  different  condi- 
tions, and  the  necessity  of  including  them  all  in  statistics  if 
accurate  results  are  to  be  obtained.  The  total  mortality  at 
four  different  hospitals  during  the  same  battle  was : 

Per  cent 
(4)     A  casualty  clearing  station 54.00 

(2)  An  advanced  operating  hospital 36.36 

(3)  An  advanced  operating  hospital 82.64 

(4)  A  casualty  clearing  station    72.73 

The  time  which  has  elapsed  between  the  receipt  of  the  in- 
jury and  the  performance  of  the  operation  influences  the  mor- 
tality. Most  cases  arrive  some  time  between  6  and  10  hours 
after  receipt   of  the   injury.     If   over   12  hours,   the   mortality 


ABSTRACTS  OF  WAR  SURGERY  201 

mounts;  above  24  hours  there  is  little  hope  of  getting  a  good 
result. 

From  the  operative  point  of  view,  the  sooner  the  patient  is 
operated  upon  the  better.  From  a  postoperative  point  of  view 
it  is  desirable  to  do  the  operation  in  some  place  where  the 
patient  can  be  kept  quiet  and  properly  nursed.  For  obvious 
reasons  it  is  not  possible  to  satisfy  both  conditions. 

Taking  it  all  in  all,  the  best  place  for  abdominal  surgery  is 
a  casualty  clearing  station,  preferably  selected  some  10,000 
yards  behind  the  line  on  a  railway  or  canal  with  good  roads 
leading  to  it.  If  a  patient  arrives  at  a  casualty  clearing  sta- 
tion 10  hours  after  the  receipt  of  a  wound  it  will  most  prob- 
ably be  found  that  only  60  minutes  have  been  spent  in  travers- 
ing the  distance  from  the  trench  system  to  the  casualty  clear- 
ing station. 

Discussing  the  mechanism  of  wound  production  after  pene- 
tration, Wallace  expresses  the  view  that  the  different  types  of 
wound  are  caused  by  the  varying  state  of  distension  of  the 
small  gut.  As  is  well  known,  one  meets  with  lengths  of  the 
small  intestine  alternately  distended  with  aid  and  collapsed. 
If  the  bullet  strikes  a  distended  portion,  it  will  perforate  it 
or  cut  a  hole  in  it.  If  it  strikes  a  portion  which  is  collapsed, 
the  intestine  is  so  small  that  the  diameter  of  the  bullet  is 
such  that  it  could  divide  both  coats. 

Wallace  directs  particular  attention  to  the  difficulties  en- 
countered in  making  a  diagnosis  of  intraperitoneal  damage. 
Even  with  all  possible  care  and  an  extensive  experience  and 
a  full  appreciation  of  the  numerous  fallacies,  it  is  frequently 
difficult  to  make  sure  that  a  wound  is  penetrating.  If  it  is 
difficult  when  there  is  an  entrance  and  exit  wound,  it  is  still 
more  so  when  there  is  only  one  wound.  Shock,  hemorrhage, 
rigidity,  a  rapid  pulse  may  be  present,  but  in  some  cases  which 
are  received  early  there  will  be  no  such  guides.  The  wound  of 
a  hollow  viscus  may  in  itself  have  no  symptoms  if  it  is  not 
extensive  enough  to  produce  shock;  it  is  usually  hemorrhage 
or  peritonitis  which  gives  the  danger  signal.  As  there  is  a  dis- 
tinct relation  between  the  interval  since  the  receipt  of  the 
wound  and  the  operation,  it  is  important  to  be  able  to  deter- 
mine  the   probability   of  penetration. 

Wallace  warns  against  making  a  negative  diagnosis  without 
great  care.  Experience  has  shown  the  wisdom  of  operating  in 
doubtful  cases.  This  is  particularly  true  of  bomb  wounds, 
which  often  are  so  small  and  insignificant  that,  as  he  says,  it 


202  ABSTRACTS  OF  WAR  SURGERY 

sometimes  takes  some  strength  of  mind  to  explore  the  abdomen, 
although  the  symptoms  point  to  the  possibility  of  visceral  in- 
volvement. 

"While,  as  a  rule,  a  man  who  has  been  hit  in  the  abdomen, 
looks  ill,  this  may  not  be  the  case.  Before  rapid  evacuation 
was  the  rule,  Wallace  was  struck  by  the  fallaciously  good  facial 
expression  of  some  of  these  cases,  when  the  hands  were  cold 
and  clammy  and  the  pulse  running  or  even  not  palpable.  Such 
cases,  he  says,  invariably  die,  and  operation  only  hastens  their 
end. 

A  rapid  pulse,  a  pulse  that  does  not  fall,  or  a  rising  pulse  is 
an  indication  for  operation.  A  slow  pulse  is  not  necessarily  a 
contraindication  unless  the  wound  is  in  a  nondangerous  area 
such  as  the  liver.  A  rapid  pulse,  which  is  caused  by  loss  of 
blood,  and  later  on  by  peritonitis  and  sepsis,  does  not  seem  to 
have  any  very  definite  connection  with  the  number  of  lesions 
of  the  intestine.  The  pulse  often  falls  with  rest  and  infusion, 
and  it  often  happens  that  a  falling  pulse  is  more  an  indication 
of  the  possibility  of  operation  than  a  contraindication  to  opera- 
tive measures.    A  rising  pulse  is  an  indication  for  operation. 

Vomiting,  in  these  cases,  has  no  special  significance  beyond 
the  fact  that  its  absence  shows  that  the  stomach  is  most  prob- 
ably not  involved. 

With  the  exception  of  blanching  and  rapid  pulse,  both  of 
which  may  be  produced  by  other  causes,  the  classical  signs  of 
hemorrhage  are  usually  absent. 

Rigidity  is  a  constant  but  varying  symptom  when  the  cases 
arrive.  It  is  seen  in  low  thoracic  injuries,  wounds  of  the  ab- 
dominal wall,  and  in  contusions  of  the  abdomen  and  with  true 
visceral  injuries. 

Shock  is  considered  under  two  heads:  (1)  Subjective  sensa- 
tions, (2)  shock  proper. 

The  subjective  sensations  of  a  man  shot  in  the  abdomen  vary 
in  a  remarkable  degree,  being  influenced  by  the  size  of  the 
projectile. 

As  regards  the  abdomen,  a  state  of  clinical  shock  is  produced 
in  various  ways — by  a  violent  blow;  by  multiple  intraperitoneal 
abdominal  injuries;  by  hemorrhage,  by  sepsis,  which  seems  to  be 
of  the  nature  of  poison  shock,  and  by  pain. 

Apart  from  certain  generalizations,  it  is  difficult  to  make  any 
definite  statement  as  to  the  relation  between  the  amount  of 
shock  present  on  the  one  hand  and  the  organs  injured  and 
the  amount  of  individual  damage  on  the  other.     There  is  con- 


ABSTRACTS  OF  WAR  SURGERY  203 

siderable  difficulty  in  ascertaining  the  connection  between  the 
actual  damage  done  and  the  amount  of  shock.  Regimental 
medical  officers  who  see  cases  early  can  form  no  idea,  apart 
from  the  loss  of  abdominal  wall  or  protrusion  of  viscera,  what 
the  extent  of  the  abdominal  injury  is,  and  by  the  time  the 
cases  come  to  operation  there  are  the  added  factors  of  loss  of 
blood  and  sepsis.  The  amount  of  shock  seems  to  be  largely 
due  to  the  loss  of  blood.  If  an  easy  method  of  supplying  this 
fluid  could  be  found,  results  might  be  greatly  improved.  The 
transfusion  of  blood  can  be  employed  only  when  conditions 
are  quiet  and  when  a  donor  is  available. 

The  care  of  the  patient  before  operation  is  important.  Dur- 
ing transit  to  the  hospital  the  man  wounded  in  the  abdomen 
is  more  comfortable  if  he  is  placed  in  such  a  position  that  his 
abdominal  muscles  are  relaxed.  "Warmth  and  morphia  are  im- 
portant.    Water,   in  reasonable    amounts,   may  be    given. 

Having  reached  the  hospital,  the  question  of  immediate  opera- 
tion arises.  On  the  whole,  Wallace  believes,  it  is  better  to  put 
the  man  to  bed  and  watch  his  condition  for  a  while  than  im- 
mediately to  subject  him  to  operation.  The  actual  moment  of 
performing  the  operation  must  be  left  to  the  judgment  of  the 
operator. 

Cumulative  experience  shows  the  wisdom  of  operation  in 
most  cases,  and  it  is  now  mostly  a  question  of  excluding  cases 
on  which  it  is  best  to  operate.  On  the  whole,  it  may  be 
said  that  a  policy  of  "look  and  see"  is  better  than  one  of 
"wait  and  see." 

Cases  which  are  best  left  alone  are:  (1)  Cases  in  very  bad 
condition;  (2)  cases  shot  high  up  in  the  abdomen  and  in  the 
liver  area,  in  the  absence  of  symptoms  of  hemorrhage;  (3)  high 
abdomino-thoracic  wounds  on  the  left  side;  (4)  cases  arriving 
late  (24  hours  is  given  as  the  usual  limit  within  which  a  pri- 
mary operation  is  likely  to  be  successful). 

The  operating  table,  in  the  Trendelenburg  position,  should 
be  ready  for  use.  Most  important  is  the  provision  of  some 
heating  arrangement  on  which  the  patient  can  lie. 

The  incision  is  planned  rather  with  a  view  of  dealing  with 
the  probable  nature  of  the  injury  than  with  any  reference  to 
the  wounds.  With  an  in-and-out  wound  the  course  of  the  pro- 
jectile is  known  and  a  fair  estimate  can  be  performed  of  the 
organs  likely  to  be  involved.  With  a  single  wound  this  is 
practically  impossible,  and  here  an  x-ray  examination  will  en- 


204  ABSTRACTS  OF  WAR  SURGERY 

able   the   operator   to   make   the   incision   in   the   best   possible 
place. 

A  paramedian  incision  is  the  standard  method  of  opening 
the  abdomen,  and  should  be  used  in  all  cases  unless  there  is 
some  distinct  indication  to  the  contrary.  It  is  always  better 
to  prolong  the  incision  than  to  make  lateral  right-angle  exten- 
sions. The  length  should  be  6  to  8  inches,  probably  the  longer 
the  better,  as  free  access  means  a  very  great  increase  in  celer- 
ity. 

In  some  anteroposterior  wounds  toward  the  lateral  line  of  the 
body  a  rectus  sheath  incision  may  be  employed.  Such  an  incision 
permits  easier  access  to  the  colon,  and  the  limiting  of  the  field 
of  operation.  The  disadvantages  are  that  it  is  not  a  good  in- 
cision to  close,  and  it  divides  many  nerves. 

Where  the  missile  has  perforated  through  the  body  from  near 
the  mid-line  to  the  loin,  whether  this  direction  is  shown  by  an 
entrance  or  an  exit  wound,  or  by  the  aid  of  a  skiagram,  the 
transverse  incision,  either  horizontal  or  parallel  to  the  upper 
or  lower  abdominal  limits,  has  much  to  recommend  it.  If  more 
room  is  required  it  can  be  obtained  by  cutting  the  anterior 
rectus  sheath,  but  leaving  the  rectus  muscle  intact.  Such  an 
incision  allows  free  access  to  the  hepatic  and  splenic  flexures, 
to  the  vertical  colons,  to  both  kidneys,  and  to  the  spleen.  It 
is  the  only  incision  that  allows  the  ascending  and  descending 
colons  to  be  easily  and  properly  repaired.  Its  posterior  ex- 
tremity is  a  convenient  situation  for  an  artificial  anus  at  the 
site  of  the  colon  wound.  It  is  not  a  convenient  incision  for 
the  stomach,  except  for  that  portion  situated  near  the  spleen. 
A  similar  incision  starting  behind  and  prolonged  forward,  if 
necessary,  can  be  used  with  advantage  in  exploring  lateral 
wounds  of  the  body  in  the  neighborhood  of  the  cecum  and 
sigmoid.  A  subcostal  incision  is  also  good  in  certain  liver 
wounds. 

In  some  cases  of  wounds  in  the  back  of  the  loin  it  is  better 
to  open  the  abdomen  in  the  mid-line  and  make  sure  that  the 
peritoneum  has  not  been  involved.  If  this  is  so,  the  wound  is 
closed  and  the  loin  opened  up  and  the  necessary  steps  taken 
to  deal  with  the  condition  found.  Such  horizontal  wounds 
suture  easily  and  heal  kindly. 

The  method  of  closure  of  the  wound  must  depend  on  the  con- 
dition of  the  patient.  If  the  condition  is  critical  it  must  be 
closed  by  through-and-through  sutures.  If  the  condition  of  the 
patient   allows  it  the  wound   can  be   closed  in  layers,  but  in 


ABSTRACTS    OF    WAR    SURGERY  205 

every  case  there  should  be  at  least  three  through-and-through 
supporting  stitches. 

Opinions  differ  concerning  abdominal  drainage.  Wallace 
never  uses  it,  nor  does  he  believe  that  it  has  any  points  to  rec- 
ommend it.  By  abdominal  drainage  is  meant  the  ordinary  drain 
to  the  pelvis  or  loins.  It  is  quite  another  thing,  he  says,  to  tie 
a  small  drain  to  a  suture  line  which  mistrusts,  the  idea  of  which 
is  to  form  a  local  track  in  the  case  of  a  leak. 

Flushing  the  abdomen  is  favored  by  some,  especially  when 
the  abdomen  is  full  of  septic  blood.  It  is  difficult,  however,  to 
flush  efficiently  without  much  exposure  of  the  intestines.  Both 
saline  and  eusol  have  been  used.  When  eusol  is  heated  to  the 
requisite  temperature  its  efficiency  is  destroyed.  The  cold  pro- 
duced by  ether  is  sufficient  to  damn  it,  in  Wallace's  opinion, 
even  if  its  use  could  cleanse  the  abdomen.  A  small  amount 
used  to  produce  leucocytosis  finds  favor  with  some. 

The  technic  and  details  of  treatment,  of  course,  vary  with 
the  organs  or  parts  involved.  The  postoperative  treatment 
differs  in  no  essential  detail  from  that  employed  in  ordinary 
surgical  practice  after  any  severe  operation. 

As  to  the  choice  of  anesthetic  in.  cases  of  abdominal  injury, 
Wallace  states  that  men  who  have  been  wounded  less  than  40 
hours  previously  are  not  good  subjects  for  spinal  anesthesia. 
Intrathecal  injection  of  stovaine  is  followed  by  a  great  fall  of 
blood  pressure,  which  may  be  fatal.  Chloroform  is  an  unsuit- 
able anesthetic.  The  blood  pressure  falls  steadily  during  the 
course  of  the  administration.  In  prolonged  operations  death 
may  occur  before  the  abdomen  is  closed,  or  during  the  next  few 
hours.  Ether  is  the  drug  most  generally  used.  Its  chief  dis- 
advantages are  loss  of  body  heat  caused  by  the  prolonged  in- 
halation of  cold  vapor,  and  irritation  of  the  respiratory  tract. 
Ether  should  not  be  given  by  the  intravenous  method  to  men 
suffering  from  shock.  Wallace  has  found  the  most  satisfac- 
tory way  of  administering  ether  or  chloroform  is  by  the  method 
which  permits  the  inhalation  of  a  warmed  mixture  of  air  and 
anesthetic  vapor.  When  the  projectile  has  entered  the  chest 
wall  as  well  as  the  abdomen,  Wallace  advocates  a  preliminary 
injection  of  hyoscine  one  one-hundreth  grain,  morphia  one- 
sixth  grain,  and  atropine  one  one-hundreth  grain,  followed  by 
a  minimal  amount  of  warm  chloroform  vapor  and  oxygen. 

The  results  obtained  by  operative  treatment  are  given  in  the 
appended  table.  The  mortality  has  been  reduced  at  the  front 
by  some  10  per  cent,  and  fewer  cases  now  die  at  the  base.    The 


206  ABSTRACTS  OF  WAR  SURGERY 

18  months  covered  by  Wallace's  observations  were  what,  as  he 
says,  is  euphemistically  called  a  quiet  time,  but  included  one 
period    of  strenuous   fighting: 

Total  number  of  cases 1,288 

Arrived   moribund 250 

Total  mortality  (excluding  moribund) .  .per  cent.  .  50.06 

"                       (including  moribund) do....  60.2 

Considered  with  view  to  operation 1,038 

No  operation  considered  advisable 73 

Total  operations 965 

Total  operative  mortality per  cent. .  53.9 

Total  hollow  viscera  mortality do.  . .  .  64.7 

Stomach  mortality1 do ... .  52.7 

Small  gut  mortality1 do ... .  65.9 

Colon  mortality1 do ... .  58.7 

By  way  of  emphasizing  the  fallacy  underlying  the  doctrine  of 
conservation  adopted  by  surgeons  in  the  Boer  War,  Armstrong 
(Lancet,  1917,  i,  p.  82;  abstracted  by  Surg.,  Gyn.,  and  Obst.)  sub- 
mits a  report  from  Lady  Paget 's  Hospital  in  Serbia.  In  Serbia, 
we  are  told,  conditions  are  similar  to  those  in  South  Africa,  and 
yet  a  far  better  outlook  for  patients  with  penetrating  abdominal 
wounds  was  furnished  by  operative  intervention  than  by  con- 
servative treatment.  He  pleads  for  operation  in  all  cases  of  per- 
forated intestine  due  to  bullet  wounds.  Twenty-four  cases  are 
reported  by  Armstrong.  Ten  consecutive  cases  of  over  30  hours' 
duration  were  explored  and  perforations  sutured  with  three  re- 
coveries. It  is  noteworthy  that  none  of  these  cases  were  drained. 
Seven  consecutive  cases  of  the  same  duration  were  treated  by 
saline,  Fowler's  position,  opiates,  stimulations,  etc.;  all  died. 
Autopsy  proved  that  two  which  were  moribund  at  admission  died 
of  hemorrhage  from  large  vessels  (gastroepiploic  and  hemor- 
rhoidal veins)  30  hours  after  injury.  Three  cases  of  probable 
injury  to  the  diaphragm  showed  an  intermittent  rigidity  of  the 
recti  muscles  lasting  for  several  minutes  with  intervals  of  flaccid- 
ity  lasting  about  an  hour.    The  sign  ceased  after  36  hours. 

The  author  contends  that  many  cases  of  "cures"  accredited  to 
the  medical  treatment  have  in  reality  probably  been  only  wounds 
of  the  abdominal  wall,  because  it  has  been  repeatedly  demonstrated 
that  a  bullet  can  cross  the  abdomen  without  causing  material 
damage  to  the  viscera. 

iUncomplicated  by  other  intestinal  lesion. 


CHEST 

GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA.— Sir  Berke- 
ley Moynihan.     Surg.,  Gynec.  and  Obst.,  December,  1917. 

The  mortality  of  chest  wounds  in  all  zones  of  the  army  is 
extremely  difficult  to  ascertain  with  anything  approaching  ac- 
curacy. Pierre  Duval,  whose  work  in  the  surgery  of  the  lungs 
during  this  war  has  been  characterized  by  originality,  insight, 
prudent  courage,  and  great  technical  success,  has  gathered  to- 
gether the  records  from  many  parts  of  the  French  Army.  Of 
a  total  of  3,455  cases  there  were  688  deaths,  roughly  a  mortal- 
ity of  30  per  cent.  But  the  mortality  differs,  as  may  well  be 
imagined,  at  various  parts  of  the  line  of  communications.  At 
the  aid  posts  it  is  terrible,  not  less  it  is  asserted  than  25  to 
30  per  cent.  At  the  ambulance  chirurgical  automobile,  or  cas- 
ualty clearing  station,  the  mortality  is  about  18  to  20  per  cent. 
In  the  base  hospitals  the  death  rate  is  about  10  per  cent.  There 
is,  it  will  be  seen,  a  progressive  diminution  in  mortality  from 
the  front  to  the  base.  Pierre  Duval  scrutinized  these  figures 
in  the  following  remarkable  way: 

At  the  aid  posts,  where  the  mortality  is  25  per  cent,  there 
will  remain  alive  of  100  patients,  75.  At  the  ambulance,  of  these 
75,  20  per  cent  will  die  and  there  will  remain  60  patients.  At 
the  base,  of  these  60,  10  per  cent  will  die,  so  that  finally  54  cases 
will  survive. 

Two  series  of  cases  falling  under  individual  observation  may 
be  quoted.  Gregorie  records  a  total  of  404  cases  of  chest 
wounds,  pure  and  simple,  i.e.,  without  other  injury,  with  47 
deaths,  a  death  rate  of  11.7  per  cent.  Of  these  75  patients  were 
operated  upon  for  empyema,  with  resection  of  the  rib  and 
drainage ;  26  died,  a  mortality  of  45  per  cent. 

All  observers  are  agreed  that  there  is  a  difference  in  the  mor- 
tality according  to  the  projectile  inflicting  the  injury.  If  a 
rifle  bullet  causes  the  wound,  the  condition  resulting  is  either 
very  serious,  if  a  large  vessel  is  struck,  or  very  benign  if  the 
lung  tissue  is  traversed  without  serious  vascular  injury. 
Wounds  with  high  explosive  shell,  the  fragment  causing  the 
wound  being  irregular  and  jagged,  when  pieces  of  clothing  or 

207 


208  ABSTRACTS  OF  WAR  SURGERY 

of  skin  are  driven  deeply  in,  are  always  serious  by  reason  of 
the  infection  that  is  so  prone  to  follow. 

Death  occurs  chiefly  from  two  causes:  from  hemorrhage  or 
from  sepsis.  Hemorrhage  is  fatal  early,  generally  within  the 
first  24  or  48  hours.  Sepsis  proves  fatal  at  a  later  stage,  gen- 
erally from  the  seventh  day  onward.  The  most  fatal  cases  are 
those  where  there  is  a  gaping  wound  of  the  chest  so  that  the 
lung  is  freely  exposed.  The  mortality  in  cases  where  the  chest 
wall  is  closed  behind  the  projectile  is  rather  less  than  one-half 
of  that  which  results  when  there  is  an  open  wound. 

The  injuries  inflicted  by  a  projectile  entering  the  chest  may 
be  considered  in  their  effects  upon  (a)  the  chest  wall,  (b)  the 
injured  lung,   (c)  the  opposite  lung. 

The  Chest  Wall. — The  damage  done  to  the  chest  wall  may 
be  of  the  most  diverse  forms.  There  may  be  a  clean  penetra- 
tion of  the  thorax  from  front  to  back  by  the  projectile.  In  many 
of  these  cases,  however,  and  in  a  still  larger  number  when 
there  is  a  shell-wound,  there  is  a  fracture  of  one  or  more  of 
the  ribs  or  of  the  scapula.  Fragments  of  bone,  tiny  spicules 
or  larger  pieces,  are  carried  into  the  chest. 

In  severer  cases  a  part  of  the  chest  wall  may  be  destroyed,  being 
driven  inward  by  a  massive  piece  of  shell  casing,  or  being  swept 
away  by  a  glancing  blow.  Few  cases  reach  a  base  hospital  in 
France,  and  still  fewer,  of  course,  in  England,  where  any  large 
portion  of  the  parietes  is  lost. 

The  Injured  Lung. — The  effects  produced  in  the  lung  are 
strictly  comparable  to  those  produced  in  other  parts  of  the 
body  by  the  various  forms  of  projectile.  The  points  of  en- 
trance and  of  exit  in  the  case  of  perforating  wounds  bear  all 
the  appearances  of  those  seen  in  the  soft  tissues  of  the  thigh. 
The  entrance  wound  is  small,  even  punctate;  the  orifice  of  exit 
is  larger,  more  irregular,  and  bears  signs  of  greater  injury,  and 
of  a  tendency  to  protrusion  of  wounded  parts.  Along  the  track 
of  the  missile  there  are  the  same  evidences  of  diffused  injury. 
The  parts  around  are  bruised  and  lacerated,  there  is  a  hemor- 
rhagic pulmonary  infiltration  of  varying,  but  often  wide,  ex- 
tent. 

The  injury  to  the  damaged  lung  is  not,  however,  confined  to 
the  path  of  the  bullet,  and  the  parts  immediately  adjacent.  The 
distant  portions  of  the  lung  or  the  pleura  bear  traces  of  lesions 
due  to  the  force  with  which  the  parts  are  struck.  There  may 
be  hemorrhages  by  contrecoup,  in  the  upper  lobe  if  the  lower 
is  wounded  or  in  the  lower  if  the  upper  is  injured,  or  in  both 


ABSTRACTS  OF  WAR  SURGERY  209 

if  the  projectile  has  passed  near  the  base  of  the  lung.  These, 
as  Duval  has  shown,  may  be  recognized  at  once  by  the  opacity 
seen  on  the  radiograph. 

Such  meager  postmortem  experience  as  exists  confirms  the 
impression  that  is  derived  from  the  clinical  examination  of 
operated  cases:  that  wounds  of  the  lung  heal  rapidly  and 
kindly. 

The  Opposite  Lung. — It  is  a  new  experience,  gained  during 
this  war  that  the  opposite  lung  suffers  damage  also.  Such 
lesions  are  frequent;  in  the  severer  cases  probably  constant. 
They  consist  in  small  or  large  hemorrhages,  beneath  the  pleura 
or  in  the  substance  of  the  lung.  In  a  late  stage  the  lung  may 
present  all  the  evidences  of  a  bronchopneumonia,  at  one  point, 
or  in  many.  The  increased  activity  imposed  upon  the  lung  by 
the  restricted  function  of  that  which  has  been  wounded,  no 
doubt  renders  it  an  easy  prey  to  any  malady. 

Hemorrhage. — When  a  missile  enters  or  traverses  the  chest 
any  of  the  vessels  contained  therein  may  be  lacerated.  If  the 
larger  vessels  in  the  mediastinal  cavities  or  in  the  root  of  the 
lung  are  divided,  the  loss  of  blood  is  so  copious  and  rapid  that 
death  results  at  once  and  the  patient  does  not  reach  even  an 
advanced  aid  post.  In  the  cases  not  immediately  fatal,  the 
blood  comes,  in  the  very  great  majority  of  cases,  from  the  lung 
tissue.  Apart  from  the  cases  dying  instantly  from  Hemorrhage, 
the  deaths  in  the  first  48  hours  are  all  due  to  loss  of  blood  from 
lung  tissue.  Both  in  the  French  and  the  English  armies,  pre- 
cocious operative  measures  are  being  adopted  in  such  cases 
with  a  degree  of  success  that  encourages  a  wide  adoption  of 
this  practice.  If  death  does  not  occur  speedily  from  hemor- 
rhage, a  recurrence  of  bleeding  is  not  often  seen.  Patients 
rarely  die  from  hemoptysis,  and  secondary  hemoptysis  is  ex- 
tremely infrequent.  The  occurrence  of  hemorrhage  through 
the  wounds  of  entry  or  of  exit  is  probably  responsible  for  the 
erroneous  belief  that  it  is  from  the  chest  wall,  from  the  inter- 
costal vessels,  that  the  blood  is  lost. 

Hemothorax. — The  amount  of  blood  extravasated  into  the 
pleural  cavity  varies  very  much,  from  a  few  ounces  up  to  4 
or  even  5  pints.  The  escape  of  blood  is  hindered  and  at  last 
arrested  by  collapse  of  the  lung,  and  by  the  pressure  exerted 
by  the  blood  which  has  already  flowed  into  the  pleural  cavity. 
The  response  of  the  pleura  to  the  contact  of  blood  is  expressed 
in  an  inflammatory  reaction  which   also  helps  in  some  degree 


210  ABSTRACTS  OF  WAR  SURGERY 

to  seal  the  leaking  orifice  though  it  also  increases  the  mass  of 
fluid  lying  in  the  chest.  The  admixture  of  fluid  effused  from 
the  pleura  accounts  for  the  fact  that  in  many  cases  the  condi- 
tion of  the  combined  fluids  does  not  conform  with  that  seen 
when  only  blood  is  extravasated.  Hemothorax  in  itself,  though 
disabling  enough  and  productive  of  such  general  effects  as  the 
loss  of  a  large  quantity  of  blood  necessarily  entails,  is  not 
dangerous  to  life  apart  from  infection.  The  most  common  as- 
sociation is  of  the  bacillus  coli  with  the  gas  gangrene  bacillus. 
The  frequency  of  infection  may  be  gauged  from  the  figures 
given  by  Captain  Henry.  Out  of  500  specimens  of  fluid  ob- 
tained by  tapping,  in  the  ordinary  routine  of  work,  195  were 
found  to  be  infected,  and  of  these  87  were  infected  by  anaerobic 
organisms.  The  aspirating  syringe  introduced  into  the  upper 
fluid  part  of  the  hemothorax  may  discover  no  organisms, 
whereas  one  made  lower  down  into  the  more  solid  fibrinous  clot 
may  give  positive  results.  The  infection  may  be  derived  from 
the  projectile  or  clothing  carried  into  the  wound  at  the  moment 
of  the  infliction,  or  may  be  derived  at  a  later  stage  from  the 
focus  in  the  lung,  or  from  the  suppurating  external  wound. 

Treatment. — Upon  one  point  all  those  who  have  been  respon- 
sible for  the  treatment  of  a  patient  with  a  chest  wound  are  in  com- 
plete and  confident  agreement.  The  earliest  and  the  most  perfect 
immobilization  is  necessary.  Movements  of  all  kinds  are  to  be 
avoided,  and  therefore  retention  of  the  wounded  man  at  the  cas- 
ualty clearing  station  for  many  days  is  a  paramount  necessity. 
The  fact  that  in  the  first  two  days  the  deaths  are  due  chiefly  to 
hemorrhage  and  in  later  stages  to  sepsis  must  direct  the  timely  and 
appropriate  treatment.  Early  operations  for  the  purpose  of  ar- 
resting hemorrhage  from  the  lung  tissue  have  been  tried  only  in 
certain  hospitals  in  either  the  French  or  the  British  zones;  but 
so  far  as  the  results  of  the  work  have  gone,  they  appear  to  justify 
a  continuance,  and  indeed  a  general  adoption,  of  the  principle  of 
early  direct  treatment  of  the  wound.  It  is,  I  think,  largely  owing 
to  the  advocacy  and  to  the  successful  practice  of  Pierre  Duval 
that  an  earlier  surgical  attack  is  now  considered  necessary  upon 
the  graver  kind  of  lung  case. 

Immediate  intervention,  according  to  Duval  should  comprise: 
(1)  Closure  of  the  chest  wall  in  cases  of  "open  thorax."  (2) 
Thoracotomy  with  suture  or  plugging  of  the  lung  in  case  of  grave 
hemorrhage  or  of  threatening  asphyxia.  (3)  Treatment  of  pro- 
gressive surgical  emphysema. 


ABSTRACTS  OF  WAR  SURGERY  211 

1.  Closure  of  the  chest  wall,  an  operation  practiced  by  Larrey 
in  the  Napoleonic  wars,  has  as  its  aim  the  suture  of  the  muscles 
and  skin  in  order  to  avoid  traumatopnea,  pneumothorax  and  a 
continuing  infection  of  the  pleura  from  the  suppurating  external 
wound.  The  results  in  the  saving  of  life  and  suffering  are  incal- 
culable. The  gravity  of  the  cases  of  "open  thorax"  can  hardly 
be  exaggerated.  When  a  part  of  the  chest  wall  has  been  torn  away, 
the  lung  often  bruised  or  lacerated,  is  exposed.  It  retracts  toward 
the  hilum  and  leaves  gaping  and  bare,  a  huge  cavity  wherein 
putrefaction  may  occur,  and  a  large  surface  from  which  absorp- 
tion can  take  place. 

2.  Thoracotomy  is  formally  indicated  in  all  cases  of  wound  of 
the  lung  causing  hemorrhage.  Suture  of  the  lung  tissue  affords 
perfect  hemostasis.  When  any  foreign  body,  projectile  or  se- 
questrum, is  felt,  the  lung  is  incised  over  it  if  necessary,  and  after 
extraction  of  the  foreign  body,  the  wound  is  stitched  up  accu- 
rately. Any  blood  lying  in  the  pleura  is  carefully  evacuated,  per- 
fect cleansing  of  the  cavity  is  insured,  and  the  wound  is  closed, 
it  may  be  after  a  gentle  wiping  of  the  parts  with  ether.  There  is 
no  need  for  drainage. 

3.  In  the  treatment  of  progressive  emphysema,  closure  of  the 
wound  in  the  lung  will  shut  off  the  channel  through  which  the  air 
escapes  into  the  tissues.  Multiple  skin  incisions  will  relieve  the 
tissues  already  distended  and  crepitant.  In  cases  of  simple  pene- 
trating wounds,  a  cleansing  and  excision  of  the  wounds  followed 
by  a  complete  approximation  of  the  edges  is  all  that  is  necessary. 
In  many  cases,  even  excision  is  not  required;  the  points  of  en- 
trance and  of  exit  may  be  cleansed  and  covered  with  a  sterile 
dressing. 

When  a  hemothorax  is  present,  no  interference  as  a  rule  is 
needed  for  some  days.  There  may  be  exceptions  to  this  rule  when 
the  rapid  or  the  large  accumulation  of  fluid  is  causing  urgent 
dyspnea  which  threatens  the  life  of  the  patient.  The  dangers  of 
early  aspiration  of  the  fluid  are,  of  course,  related  to  the  reopening 
of  the  pulmonary  wound,  which,  lightly  sealed,  may  bleed  afresh, 
as  the  lung  expands.  At  the  end  of  a  week  or  thereabouts,  aspira- 
tion of  the  blood  has  probably  a  most  beneficial  effect  upon  the 
lung,  allowing  it  to  expand  much  more  rapidly  than  would  other- 
wise be  possible  and  preventing  the  formation  of  those  dense  crip- 
pling adhesions  which  may  embarrass  the  free  action  of  the  lung 
for  a  long  time  to  come,  or  even  permanently.  Operation  on  cases 
in  England,  in  which  the  blood  has  been  left  in  the  pleural  cavity, 


212  ABSTRACTS  OF  WAR  SURGERY 

reveal  an  extreme  density  and  a  wide  extent  of  adhesions.  X-ray 
examination  also  demonstrates  the  firm  union  that  is  formed  be- 
tween the  two  layers  of  the  pleura.  Withdrawal  of  the  fluid  is 
therefore  most  desirable;  its  replacement  during  aspiration  by 
oxygen  allows  more  fluid  to  be  taken,  and  causes  the  minimum  of 
distress  to  the  patient. 

In  cases  of  large  hemothorax  which  presumably  have  remained 
sterile  and  in  which  no  active  treatment  has  been  adopted,  there 
is  a  protracted  period  of  incapacity  of  the  lung. 

"When  a  hemothorax  has  become  infected,  then  thoracotomy  is 
necessary.  In  the  early  period  of  the  war  the  operation  was  prac- 
ticed on  the  lines  of  the  civil  operation  for  empyema.  A  short 
piece  of  rib  was  excised,  the  putrid  and  most  offensive  fluid  evac- 
uated, and  a  large  drainage  tube  introduced.  Such  cases  remain 
sometimes  for  weeks,  even  for  months,  with  open  wounds.  Tuffier 
has  modified,  profoundly  for  the  better,  the  treatment  of  these  tedi- 
ous and  most  trying  cases  by  adapting  to  their  needs  the  Carrel- 
Dakin  technic.  The  operation,  in  so  far  as  resection  of  the  rib  and 
evacuation  of  the  fluid  are  concerned,  is  precisely  similar  to  the 
procedure  in  cases  of  empyema.  But  instead  of  one  large  tube, 
several  small  tubes  threaded  with  wire  are  placed  over  the  cavity 
at  well  judged  intervals.  Their  position  and  proper  distribution 
may  be  confirmed  if  roentgenogram  is  taken.  A  little  loose  gauze 
is  packed  into  the  wound  and  a  safety  tube,  for  drainage  of  excess 
fluid,  lies  in  one  angle  of  the  incision.  Dakin's  fluid  is  instilled 
in  the  usual  manner.  At  the  end  of  ten  days  all  discharge  (there 
is  rarely  more  than  an  extremely  small  quantity  after  the  first 
two  days)  has  ceased,  and  the  tubes  are  therefore  removed  and  the 
wound  closed. 

There  is  no  doubt  that  many  cases  of  suppurating  hemothorax 
would  do  better  if  operated  upon  quite  early,  by  a  wide  opening  of 
the  chest,  and  a  complete  clearing  away  of  all  masses  of  clot  and 
pleural  lymph  often  so  tenaciously  adherent,  and  by  removal  of 
any  projectiles.  Patients  not  operated  upon  or  operated  upon  by 
the  older  methods  linger  on  in  unsatisfactory  condition  for  such 
long  periods  at  home,  that  every  fair  opportunity  that  offers  for 
curtailing  the  tedious  and  not  wholly  safe  period  of  their  con- 
valescence must  be  embraced.  The  Carrel-Dakin  technic  will  here 
find  one  of  its  most  valuable  indications.  This  is  only  to  bring 
the  treatment  of  wounds  of  the  lung  into  line  with  that  practiced 
elsewhere. 

"What  is  the  history  of  patients  in  whose  lungs  projectiles  are 


ABSTRACTS  OF  WAR  SURGERY  213 

retained?  Our  knowledge  does  not  allow  us  as  yet  to  answer  this 
question  fully.  But  a  certain  experience  is  not  likely  to  be  changed 
by  a  larger  survey  of  cases.  We  may  say  with  confidence  that  a 
rifle  bullet,  or  a  small  piece  of  shell  casing,  may  be  retained  for 
months  or  years  without  causing  distress  and  without  affecting 
appreciably  the  normal  functions  of  the  lung  in  which  it  lies  bur- 
ied. But  with  large  or  irregular  pieces  of  shell  the  case  is  differ- 
ent. 

For  these  reasons  I  have  recently  given  special  attention  to 
these  patients  and  have  submitted  a  number  of  them  to  operation. 
The  results  so  far  entitle  me  to  say  that  it  is  probably  a  safer,  as 
it  is  certainly  a  speedier,  procedure  to  submit  all  patients,  in  whose 
lungs  a  large  projectile  is  retained,  to  operation  rather  than  to 
leave  them  untreated.  In  almost  every  case  operated  upon  the  pro- 
jectile has  been  dropped  at  once  into  a  culture  medium ;  with  one 
exception  all  missiles  were  infected ;  the  organisms  most  commonly 
found  were  staphylococci. 

The  following  are  the  details  of  the  procedure  adopted  for  the 
extraction  of  bullets  from  the  lung.  The  new  features  in  the 
method  are  chiefly  due  to  the  initiative  and  the  superb  technical 
skill  of  Pierre  Duval : 

The  patient  lies  flat  on  his  back,  with  the  arms  to  the  side,  under 
the  oxygen  anesthesia.  A  curved  incision  about  five  or  six  inches 
in  length  is  made  exactly  along  the  line  of  the  fourth  rib.  The 
fibers  of  the  pectoralis  major  are  split,  and  the  pectoralis  minor 
separated  from  the  rib.  There  are  many  points  of  hemorrhage 
requiring  a  clip  or  a  ligature.  All  must  be  carefully  secured  so 
that  there  is  a  perfectly  dry  field.  The  rib  and  the  costal  cartilage 
are  exposed  for  a  distance  of  not  less  than  five  inches.  An  incision 
is  made  through  the  periosteum  midway  between  the  upper  and 
lower  borders  of  this  membrane  is  stripped  from  rib  on  both  sur- 
faces. A  Doyen's  curved  raspatory  is  very  useful  for  the  purpose. 
Care  is  taken  in  excising  the  rib  and  in  lifting  it  away  not  to  wound 
the  pleura,  which  must  be  separated  widely  from  the  ribs  above 
and  below,  to  the  inner  and  the  outer  side  of  the  wound.  Unless 
this  is  done,  accurate  closure  of  the  pleura  later  on,  always  diffi- 
cult, will  be  impossible.  A  retractor  is  now  placed  in  the  wound 
to  widen  the  interval  between  the  ribs  above  and  below.  Any  ab- 
dominal retractor  will  do ;  but  the  best  instrument  is  that  invented 
for  this  special  purpose  by  Tuffier.  As  wide  a  gap  as  possible  is 
made,  so  that  the  whole  hand  can  be  easily  passed  into  the  chest. 

The  pleura  is  now  incised  along  the  line  of  the  rib  and  air  enters 


214  ABSTRACTS  OF  WAR  SURGERY 

freely  and  at  once  into  the  pleural  cavity.  As  a  rule  this  causes 
no  disturbance  and  does  not  alter  the  rate  of  the  respirations  or 
the  pulse. 

The  hand  is  now  passed  into  the  chest  cavity.  Adhesions  of  the 
lung  to  the  parietal  pleura  may  be  encountered.  These  are  some- 
times very  slender  and  easily  broken  through.  At  times  they  are 
tough  and  strong  and  are  with  great  difficulty  severed.  If  they  are 
numerous  or  thick  and  tough,  bleeding  may  occur  quite  freely 
for  a  minute  or  two.  With  gentle  pressure  from  a  hot  moist  swab, 
the  oozing  is  soon  checked.  Thoracic  adhesions  bleed,  I  think,  far 
more  freely  than  those  encountered  in  the  abdomen.  When  all  are 
loosened,  the  collapsed  lung  lies  free  within  the  pleural  cavity.  It 
may  now  be  seized  with  the  fingers  or  with  a  special  light  form  of 
clip  and  drawn  up  to  the  anterior  wound,  and,  little  by  little,  be 
coaxed  out  of  the  wound.  It  is  surrounded  as  it  appears  by  warm 
cloths  soaked  in  normal  saline  solution.  When  a  lobe  of  the  lung 
is  freely  delivered  it  is  palpated  from  top  to  bottom.  Any  projec- 
tile embedded  in  it  is  felt  as  a  rule  at  once.  Even  little  sequestra 
blown  in  from  a  rib  may  be  recognized  without  any  difficulty. 
These  foreign  bodies  are  as  easily  recognized  as  the  particles  of 
gritty  sand  in  a  new  sponge.  When  the  projectile  is  felt,  the  part 
of  the  lung  containing  it  is  made  prominent,  the  lung  tissue  lying 
over  it  is  incised,  the  metal  removed,  and  the  wound  sutured.  Deep 
stitches  of  catgut  are  passed  through  the  lung  substance,  and  with 
gentle  tension  act  as  a  hemostatic. 

If  necessary  very  fine  catgut  sutures  may  be  used  to  secure  the 
accurate  apposition  of  the  pleural  edges.  If  there  is  any  bleeding 
from  the  collapsed  lung,  it  is  slight  and  easily  controlled,  but  pre- 
cision in  suture  is  most  desirable,  for  expansion  of  the  lung  will 
rapidly  be  secured  when  the  operation  is  completed.  When  the 
sutures  are  completed  the  lung  is  replaced,  the  cavity  of  the  pleura 
most  carefully  dried,  and  emptied  and  a  gauze  swab  wet  with  ether 
wiped  over  the  visceral  pleura,  and  over  any  adhesions  which  may 
have  been  separated.  The  retractor  is  removed  and  the  parietal 
pleura  now  stitched  up.  This  is  quite  the  most  difficult  part  of  the 
operation,  indeed  I  have  not  been  able  to  close  the  pleura  accur- 
ately unless  this  membrane  has  been  stripped  up  freely  from  the 
chest  wall  before  being  incised.  The  rib,  if  it  has  been  turned 
back,  is  replaced,  and  fixed  in  position  by  a  suture  through  the  cos- 
tal cartilage.  The  muscles  are  carefully  sutured  and  the  wound 
edges  accurately  approximated  without  drainage.  The  closure  of 
the  wound  should  be  so  carefully  done  as  to  seal  the  chest  hermet- 


ABSTRACTS  OF  WAR  SURGERY  215 

ically.     When  the  dressing  is  applied,  a  two-way  needle  may  be 
plunged  into  the  chest,  and  the  ether  and  air  extracted  therefrom. 
The  lung  then  rapidly  expands  and  faint  breath  sounds  are  heard 
at  once.    No  shock  follows  this  operation. 
Conclusions. — The  following  general  conclusions  may  be  stated: 

1.  The  approximate  mortality  from  gunshot  wounds  of  the 
chest  at  all  parts  of  the  line  of  communication  is  20  per  cent. 

2.  The  causes  of  death  are  hemorrhage  as  a  rule  within  28 
hours;  and  sepsis  after  the  third  or  fourth  day. 

3.  The  local  conditions  in  wounds  of  the  chest  wall  and  lung 
are  in  all  respects  similar  to  those  met  with  in  wounds  elsewhere. 
The  missiles  are  the  same,  their  destructive  effects  upon  the  tissues 
are  the  same,  and  the  infecting  organisms  are  the  same. 

4.  The  lung  tissue  is  more  resistant  to  attack  than  many  other 
tissues.  The  opening  of  the  pleural  cavity  and  the  resulting  ex- 
posure of  a  large  serous  sac  to  infection  and  all  its  consequences 
add,  however,  a  danger  of  the  most  threatening  character. 

5.  The  chief  essential  in  the  treatment  of  all  cases  of  penetrating 
wounds  of  the  chest  is  rest. 

6.  In  clean  perforating  wounds  of  the  chest  rest,  together  with 
the  cleansing  and  dressing  of  the  wound  of  entrance  or  exit,  will 
lead  to  the  recovery  of  the  great  majority  of  cases. 

7.  In  cases  of  "open  thorax,"  the  earliest  and  most  complete 
effort  possible  must  be  made  to  secure  closure  of  the  wound  after 
an  appropriate  toilet. 

8.  In  these  rare  cases  of  grave  hemorrhage,  when  hemoptysis 
is  present  or  when  the  blood  escapes  by  the  wound,  a  direct  access  to 
the  source  of  the  bleeding  must  be  obtained,  when  all  contingent 
circumstances  permit,  and  the  wound  in  the  lung  must  be  treated 
by  suture,  preferably ;  or  by  plugging  of  the  cavity  from  which  the 
blood  escapes. 

9.  In  cases  of  hemothorax  when  the  blood  effused  is  small  in 
quantity  and  remains  sterile,  no  active  measures  are  necessary, 
unless  absorption  is  long  delayed.  Aspiration,  repeated  if  neces- 
sary, may  then  be  performed. 

10.  In  cases  of  hemothorax,  when  the  blood  effused  is  large  in 
amount  and  remains  sterile,  aspiration  after  the  seventh  or 
eighth  day,  or  earlier  in  cases  of  urgent  dyspnea,  certainly  hastens 
convalescence,  permits  a  more  rapid  expansion  of  the  lung,  and 
prevents  the  formation  of  firm  adhesions  which  may  perma- 
nently cripple  the  free  movement  of  the  lung. 

11.  In  cases  of  hemothorax,  whether  the  amount  of  blood  is 


216  ABSTRACTS  OF  WAR  SURGERY 

small  or  large,  when  infection  takes  place,  open  operation  is  neces- 
sary. Early  operation  both  when  the  Carrel-Dakin  technic  or 
Morison  method  are  adopted  saves  many  weeks  of  convalescence 
and  permits  of  a  more  perfect  functional  recovery. 

12.  Small  foreign  bodies,  or  rifle  bullets,  imbedded  in  the  lung, 
often  cause  no  symptoms ;  they  become  encapsulated  and  may  safely 
be  left. 

13.  Larger  foreign  bodies  retained  in  the  lung  may  cause  dis- 
tressing or  disabling  symptoms  for  long  periods.  In  such  cases 
removal  after  resection  or  elevation  of  the  fourth  rib  through  an 
anterior  incision  will  allow  of  the  safe  removal  of  the  projectile 
from  any  part  of  the  lung.  Pieces  of  metal  so  removed  are  al- 
most always  infected. 

TREATMENT  OF  PENETRATING  GUNSHOT  WOUNDS  OF 
THE  CHEST.— X.  Delore,  and  L.  Armand.  Lyon  chir.,  1917, 
xiv,  p.  280. 

The  authors  treated  and  followed  71  penetrating  chest  wounds 
with  46  recoveries  and  25  deaths.  Of  the  71  injuries  18  were  due 
to  rifle  bullets,  five  to  shrapnel  balls,  and  48  were  shell  wounds, 
15  of  the  deaths  being  due  to  the  last. 

Regarding  the  treatment  of  such  wounds  the  authors  recommend 
the  following: 

1.  For  punctiform  wounds,  medical  treatment  only:  complete 
immobilization  of  the  chest,  large  doses  of  morphine — 3  to  4  cen- 
tigrams daily.  These  wounds  due  to  rifle  bullets  are  not  usually 
infected  and  are  rarely  associated  with  severe  vascular  lesions. 
But  if  the  bullet  wound  shows  any  symptoms  of  abdominal  pene- 
tration then  immediate  operation  is  necessary  and  the  authors  pre- 
fer an  abdominal  operation.  Contraction  of  the  abdominal  wall  as  a 
single  symptom  does  not  authorize  a  laparotomy  as  it  often  exists 
when  the  wound  is  confined  to  the  chest  alone. 

2.  For  large  wounds  the  authors  advise  operation  as  early  as 
possible  even  if  the  man  is  severely  shocked.  The  procedure  after 
x-ray  examination  is: 

(a)  A  parietal  wound  is  widely  opened  up  and  thoroughly 
cleansed,  all  foreign  bodies,  pieces  of  ribs  and  manubrium  removed 
and  the  remaining  bone  surfaces  smoothed;  the  injured  soft  parts 
are  cut  away.    After  careful  hemostasis  if  the  projectile  has  not 


ABSTRACTS  OF  WAR  SURGERY  217 

penetrated  the  lung  the  pleura  is  cleansed,  sutured  if  lacerated, 
and  wound  dressed. 

(b)  If  the  projectile  has  penetrated  the  lung,  the  gap  is  enlarged, 
any  blood  found  in  the  pleural  cavity  is  removed,  and  the  pleural 
sinuses,  lung,  and  diaphragm  thoroughly  examined.  It  is  useful  to 
operate  under  the  radioscopic  screen.  The  lung  may  be  drawn 
out  of  the  wound  if  the  projectile  is  situated  deeply ;  and  if  not  clin- 
ically infected  nor  too  much  lacerated  it  may  be  sutured  as  well  as 
the  pleura.  If  not,  the  edges  of  the  lung  wound  must  be  fixed  to  the 
wound  of  the  skin  by  some  catgut  stitches  to  avoid  a  later  retrac- 
tion. 

(c)  If  there  is  a  wound  of  the  diaphragm  it  is  enlarged  suffi- 
ciently to  explore  the  liver  or  spleen.  If  the  latter  is  injured,  its 
removal  through  the  gap  is  easy.  A  wound  of  the  upper  surface 
of  the  liver  may  be  plugged  with  a  gauze  tampon. 

(d)  If  other  abdominal  organs  appear  to  be  injured,  a  com- 
plementary laparotomy  will  be  necessary  after  closure  of  the  dia- 
phragm wound.  Even  in  those  cases  where  abdominal  symptoms 
predominate  the  authors  begin  the  operation  by  the  treatment  of 
the  chest  wound  which  often  avoids  a  laparotomy  and  at  all  events 
prevents  all  secondary  complications  from  the  pleura  or  the  lung. 

IS  THORACOTOMY  INDICATED  IN  THE  TREATMENT  OF 
WOUNDS  OF  THE  CHEST  TO  ARREST  HEMORRHAGE? 

— Hartmann.     Bull,  et    mem.     Soc.  de  chir.  de  Paris,  1917, 
xliii,  p.  404. 

Hartmann  takes  exception  to  a  recent  recommendation  of  Duval 
favoring  early  thoracotomy  in  the  case  of  chest  wounds  with  ex- 
tensive hemorrhage.  From  inquiries  made  of  several  of  the  automo- 
bile surgical  ambulance  services,  Hartmann  finds  that  in  cases 
where  thoracotomy  is  not  done  the  mortality  varies  from  12.7  to 
18  per  cent,  which  is  the  same  percentage  reported  by  Duval  with 
thoracotomy.  Moreover,  no  report  is  given  of  any  patient  dying 
from  hemorrhage  in  the  statistics  gathered  by  Hartmann.  He  is 
therefore  of  the  opinion  that  thoracotomy,  as  a  preliminary  to 
hemostasis  of  the  lung,  although  theoretically  rational,  is  not  in- 
dicated. 

Duval,  in  the  discussion,  brought  forward  some  additional  cases 
to  those  included  in  his  first  report  making  the  mortality  of  all 
his  cases  32.1  and  the  recoveries  67.9  per  cent.    He  reiterated  that 


218  ABSTRACTS  OF  WAR  SURGERY 

in  severe  hemorrhages  thoracotomy  with  suture  of  the  lungs  saves 
two-thirds  of  the  patients. 


INFECTION  OF  HEMOTHORAX  BY  ANAEROBIC  GAS-PRO- 
DUCING BACILLI.— T.  R.  Elliott.  Brit.  Med.  Jour.,  1917, 
i,  pp.  413,  448. 

One-fourth  of  all  cases  of  hemothorax  from  gunshot  wounds  of 
the  chest  are  infected,  and  because  of  this  frequency  early  explora- 
tion for  bacteriological  infection  is  adopted  in  all  military  hos- 
pitals. 

This  paper  deals  with  the  growth  in  a  hemothorax  of  certain  an- 
aerobic bacilli  producing  gas.  In  a  series  of  195  cases  of  septic 
hemothorax,  87  or  44.6  per  cent  were  infected  with  such  bacilli. 

After  a  latent  period  of  varying  duration,  the  gas  and  poisons 
produced  by  the  bacilli  may  develop,  in  many  instances  with 
fulminating  rapidity,  amid  the  hemothorax,  so  that  a  case  which 
on  the  second  or  third  day  following  the  wound  was  regarded 
only  with  suspicion  of  sepsis  has  often  been  seen  to  pass  in  the 
next  forty-eight  hours  into  a  state  of  the  gravest  danger.  How- 
ever, under  the  present  methods  of  early  diagnosis  and  proper 
treatment,  the  mortality  has  been  reduced  to  10  or  15  per  cent. 
There  is  a  greater  liability  for  anaerobic  bacilli  to  be  carried 
in  by  shell  fragments  than  by  rifle  bullets. 

The  infection  may  be  a  generalized  form  being  disseminated 
throughout  the  fluid  hemothorax,  or  it  may  be  localized  in  a  mass 
of  blood-clot  lying  at  the  bottom  of  the  pleural  cavity  to  begin 
with  and  later  disseminated  by  the  organisms  escaping  through 
the  blood-clot  to  the  entire  fluid  hemothorax. 

The  exploring  needle  is  the  most  valuable  means  of  arriving  at 
an  early  accurate  diagnosis  and  should  be  used  daily  whenever 
doubt  arises.  An  offensive  odor  of  the  sample  withdrawn  justi- 
fies surgical  treatment  at  once.  Several  varieties  of  fluid  may  be 
obtained : 

(a)  Blood  with  an  offensive  odor,  purple  color  which  is  darker 
and  more  transparent  than  venous  blood.  The  purple  color  is 
characteristic  of  an  infection  by  anaerobic  bacilli,  but  the  foul 
smell  is  the  chief  criterion. 

(b)  A  fluid  loaded  with  pus,  reddish-pink  or  deep  buff  in 
color,  slightly  or  not  at  all  offensive. 


ABSTRACTS  OF  WAR  SURGERY  219 

(c)  A  red  fluid  like  ordinary  sterile  hemothorax  fluid,  but 
containing  bacilli,  on  culture. 

(d)  A  yellow  serous  fluid  containing  bacilli  on  culture. 

The  offensive  odor  is  the  only  criterion  which  can  be  accepted 
without  further  study. 

The  examination  of  hemothorax  fluids  consists  of  the  immediate 
microscopic  examination  of  the  fluid  or  the  centrifuged  product, 
and  the  preparation  from  it  of  both  aerobic  and  anaerobic  cul- 
tures. Methylene  blue  and  gram  stains  are  made.  Many  organ- 
isms may  be  found  in  the  examination  of  these  hemothorax  fluids; 
however,  the  strong  gram  positive  bacilli  are  the  gas-producing 
organisms.  The  examination  of  morphological  features  in  a 
film  is  never  sufficient  for  their  identification  but  must  be  supple- 
mented by  cultural  test.  Both  aerobic  and  anaerobic  cultures 
are  made. 

The  gas-producing  organisms  of  most  importance  are  the  bacil- 
lus perfringens  and  bacillus  sporogenes. 

The  clinical  features  of  these  septic  hemothorax  cases  may  be 
classified  under  three  heads :  ( 1 )  those  indicating  a  general 
toxic  action  on  the  patient  of  the  septic  substances  produced;  (2) 
those  caused  by  inflammation  of  the  pleural  cavity;  (3)  the  spe- 
cial physical  signs  within  the  chest. 

Jaundice,  especially  if  associated  with  epistaxis,  is  an  index 
of  very  severe  type  of  infection  by  anaerobes. 

The  forms  of  infection  of  a  hemothorax  by  the  anaerobic  gas 
bacilli  fall  clinically  into  five  groups  which  are  differentiated  by 
the  predominance  of  toxic  symptoms  of  the  features  of  gas  for- 
mation respectively. 

These  may  be  fatal  in  two  or  three  days. 

The  conclusions  are: 

1.  Infection  by  anaerobic  bacilli  occurs  in  about  10  per  cent 
of  all  cases  of  hemothorax  from  gunshot  wounds  of  the  chest. 

2.  The  infection  leads  to  the  development  of  malodorous  gas. 

3.  In  the  majority  of  cases  the  septic  features  are  much  more 
prominent  than  gas  formation. 

4.  Diagnosis  depends  upon  exploratory  puncture. 

5.  Life  can  be  saved  in  at  least  80  per  cent  of  the  cases  if  the 
infected  blood  is  drained  away. 


220  ABSTRACTS  OF  WAR  SURGERY 

PROJECTILES  IN  THE  PLEURAL  CAVITY;  DIFFERENT 
BEHAVIOR  OF  THE  PLEURA  ACCORDING  TO  THE 
FORM  OF  THE  PROJECTILE.— G.  Cresole.  Gazz.  d.  osp. 
e.  d.  din.,  Milan,  1917,  xxxviii,  p.  51. 

From  the  clinical  and  radioscopic  examination  of  three  cases 
the  author  states  that,  quite  independently  of  any  pleural  in- 
flammatory process,  the  pleura,  in  the  presence  of  a  foreign  body 
with  a  rough,  uneven  surface,  may  originate  an  aseptic  reaction 
capable  of  organized  products  which  will  encapsulate  the  foreign 
body ;  but  that  when  such  foreign  body  has  a  smooth  and  aseptic 
surface  such  reaction  on  the  part  of  the  pleura  is  lacking,  and 
the  body  remains  free  in  the  pleural  cavity. 

EXTRACTION  OF  INTRAPULMONARY  PROJECTILES  UN- 
DER THE  SCREEN.— E.  Petit  de  la  Villeon.  Presse  mid., 
1917,  p.  301. 

Petit  de  la  Villeon 's  experiences  are  based  on  200  operations 
for  the  extraction  of  230  intrapulmonary  projectiles.  All  recov- 
ered except  one,  and  in  most  cases  the  recovery  was  rapid  after 
extraction. 

The  forceps  extraction  under  screen  control  is  the  adaptation 
of  general  radio-operative  methods  to  pulmonary  surgery.  The 
entrance  of  the  x-ray  not  only  into  diagnosis  but  also  into  opera- 
tive procedures  has  given  surgery  a  new  turn.  Instead  of  the 
older  methods  of  large  open  dissections  there  is  now  what  may 
be  termed  the  economic  radio-operative  method,  economical  be- 
cause it  avoids  unnecessary  opening  up  and  unnecessary  surgical 
procedures. 

To  the  objection  that  the  method  is  blind  and  nonanatomical 
it  may  be  replied  that  the  contrary  is  the  fact.  A  thorough  prac- 
tical knowledge  of  regional  anatomy  as  well  as  the  acquired  abil- 
ity to  "see"  under  the  screen  is  necessary.  This  is  essential  to 
pick  out  the  organs  involved  as  well  as  the  best  and  safest  route 
of  approach  to  the  projectile  by  a  simple  and  economic  opera- 
tion. 

The  author  gives  the  technic  and  indications  for  the  removal  of 
intrapulmonary  projectiles.  The  contraindications  to  the  radio- 
operative  method  are :  (1)  projectiles  situated  in  the  hilum 
region  of  the  lung;  (2)  very  voluminous  projectiles  or  fragments; 
(3)  when  there  is  an  abscess  around  the  projectile. 


ABSTRACTS  OF  WAR  SURGERY  221 

In  the  case  of  projectiles  in  the  hilum  region  the  author  prac- 
tices inter-omo-vertebral  thoracopneumotomy  in  three  stages, 
which  he  describes  in  detail. 


TECHNIC  OF  THE  EXTRACTION  OF  FOREIGN  BODIES  IN 
THE  MEDIASTINUM,  BY  THE  TRANSPLEURAL  ROUTE 
WITH  AN  ANTERIOR  COSTAL  OPENING  AND  OTHER 
METHODS;  OPERATIVE  RESULTS.— R.  Le  Fort.  Bull. 
et  mem.  Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  26. 

The  surgical  rule  of  the  present  day  is  to  extract  projectiles 
from  the  lung,  and  allow  those  of  the  mediastinum  to  remain.  But 
projectiles  of  the  lung  which  become  encysted  are  often  well  tol- 
erated and  are  infinitely  less  dangerous  than  those  of  the  medias- 
tinum situated  near  the  heart  and  large  vessels  and  which  are  al- 
ways moving  in  the  midst  of  delicate  organs. 

For  many  reasons  surgery  of  the  mediastinum  is  not  well  es- 
tablished. The  occasions  for  practice  are  rare ;  published  obser- 
vations and  cadaver  experiments  do  not  give  much  help ;  the 
routes  of  approach  are  difficult  and  interventions  are  reputed  to 
be  very  dangerous. 

Le  Fort's  object  in  making  this  report  is  to  give  a  precise  tech- 
nic  supported  by  integral  statistics  which  demonstrate  that  a  well- 
conducted  operation  is  not  very  serious.  It  is  indispensable  that 
such  surgery  should  be  undertaken  only  by  experienced  operators. 

Le  Fort's  experience  is  based  on  30  operations  in  the  three  fol- 
lowing groups: 

1.  Operations  on  the  mediastinum  for  abscess,  thymic  tumors, 
stab  wounds,  etc. 

2.  Operations  undertaken  for  the  extraction  of  foreign  bodies, 
but  which  proved  to  be  situated  outside  the  mediastinal  pleura. 

3.  Operation  for  extraction  of  foreign  bodies  which  were  sit- 
uated between  the  right  mediastinal  pleura  and  left  mediastinal 
wound  or  intramediastinally. 

The  best  method  of  approach  in  the  majority  of  cases  is  the 
anterior  transpleural  route  through  the  costal  opening.  The 
route  remains  good  in  case  of  a  projectile  deemed  to  be  medias- 
tinal but  which  in  reality  is  situated  in  the  pleural  cavity  or  in 
the  pulmonary  parenchyma. 

Before  intervention,  except  for  urgency,  cicatrization  of  anter- 
ior thoracic  wounds  must  be  awaited.  Le  Fort  gives  the  full  de- 


222  ABSTRACTS  OF  WAR  SURGERY 

tails  of  his  method  of  extraction  of  foreign  bodies  by  this  route 
removing  a  costal  flap.  This  includes  the  selection  of  the  side  of 
the  thorax,  the  ribs  included  in  the  flap,  the  cutting  of  the  flap ; 
mediastinal  liberations ;  search  for  the  foreign  body ;  and  extrac- 
tion with  closure  of  the  wound. 

Pneumothorax  is  remarkably  well  supported  and  there  does 
not  appear  to  be  much  more  inconvenience  in  a  large  opening  of 
the  pleura  than  of  the  peritoneum.  Flattening  of  the  lung  against 
the  vertebral  column  in  pleural  incisions  is  only  a  fable ;  it  occurs 
only  in  the  cadaver.  It  is  not  necessary  to  puncture  in  order  to 
extract  air  remaining  in  the  wound  after  operation.  Le  Fort 
has  not  done  it  in  any  of  his  cases.  The  efforts  of  the  patient  will 
drive  out  in  part  any  air  remaining  in  the  cellular  tissues. 

But  this  method  of  operation  by  anterior  costal  flap  is  not  the 
only  one  to  be  recommended;  there  are  other  methods  for  which 
there  may  be  formal  indications,  viz. : 

1.  Simple  intercostal  incisions  with  or  without  a  limited  resec- 
tion of  one  rib  (for  foreign  bodies  easily  reached). 

2.  Anterolateral  transpleural  route  with  large  resection  of  the 
sixth  rib.  This  provides  ample  opening  of  the  inferior  medias- 
tinal zone  and  of  the  diaphragm. 

3.  Posterior  transpleural  route,  which  gives  access,  limited  to 
the  aorta,  brachiocephalic  trunk,  etc. 

4.  Extrapleural  route.  By  this  route  access  can  be  obtained 
to  foreign  bodies  situated  in  front  of  the  two  first  dorsal  verta- 
brse. 

The  approach  varies  for  the  anterior  and  posterior  medias- 
tinum. 

Le  Fort  calls  attention  to  the  absolute  necessity  of  a  complete 
radiologic  study  before  any  intervention.  This  will  give  the 
geometric  localization  of  the  foreign  body ;  the  anatomic  localiza- 
tion and  the  relations  to  the  surrounding  organs;  the  physiolog- 
ical localization  movements  communicated  from  the  heart,  dia- 
phragm, and  vessels. 

La  Fort  expects  soon  to  publish  all  the  details  of  his  interven- 
tions of  the  various  kinds  enumerated.  He  gives  a  short  account 
of  15  operations  for  extraction  of  intermediastinal  projectiles, 
with  only  one  death.  In  14  of  these  cases  the  foreign  body  was 
extracted.    The  postoperative  course  was  as  a  rule  simple. 

In  the  discussion  following  the  paper  opinions  were  divided. 


ABSTRACTS  OF  WAR  SURGERY  223 

Those  who  criticised  Le  Fort's  procedure  expressed  the  opinion 
that  the  costal  resection  should  be  limited  to  a  single  rib. 

EXTRACTION  OF  INTRATHORACIC  PROJECTILES.— Binet 

and  Masmenteil.    Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1917, 
xliii,  p.  78. 

The  difficulties  met  with  in  the  extraction  of  mediastinal  pro- 
jectiles have  been  exposed  in  a  recent  report  by  Le  Fort.  The 
authors  in  107  cases  found  15  intrathoracic  projectiles — exclud- 
ing intrapleural,  intrapulmonary,  and  intracardiac.  Of  these,  7 
were  mediastinal,  5  being  anterior  and  2  posterior  mediastinal  pro- 
jectiles; 3  were  juxtacardiac  in  contact  with  the  pericardium. 
The  majority  were  small  pieces  of  shell. 

The  authors  studied  in  detail  the  route  of  approach  on  the 
mediastinum.  When  the  projectile  is  seen  radioscopically  above 
the  third  rib,  in  front  and  above  the  fifth  spinous  process  behind, 
they  approach  it  by  the  anterior  route.  Below  this  zone  which  cor- 
responds to  the  pulmonary  hilum  they  prefer  a  lateroposterior 
incision.  Foreign  bodies  included  in  the  diaphragm  can  be 
reached  by  a  thoracico-abdominal  incision. 

The  superficial  or  deep  position  of  the  projectile  rather  than 
other  circumstances  determines  the  method  of  excision.  The 
authors  reserve  the  thoracic  flap  for  cases  where  the  foreign 
body  is  in  a  dangerous  zone  in  the  vicinity  of  large  vessels,  in 
which  case  it  is  necessary  to  have  a  full  and  clear  field  of  obser- 
vation so  that  grave  accidents  may  be  avoided.  They  agree  with 
Le  Fort  that  for  the  upper  mediastinum  large  rib  resections  com- 
prising the  second,  third,  and  fourth  ribs,  and  for  the  lower 
mediastinum,  the  third,  fourth,  and  fifth  ribs,  are  desirable. 
The  pleura  should  not  be  exposed  unless  necessary,  but  if  neces- 
sary it  should  be  fully  opened  up  without  fear  of  any  result- 
ing pneumothorax,  the  dangers  of  which  have  been  greatly  ex- 
aggerated. 

All  cases  operated  upon  by  the  authors  have  recovered  and 
primary  union  has  been  obtained  in  all  cases  except  one. 

WAR  WOUNDS  OF  THE  LARYNX  AND  TRACHEA.— E.  J. 

Moure.    Rev.  de  chir.,  1916,  xxxv,  II  sem.,  1. 

Military  statistics  show  that  laryngotracheal  injuries  are  not 
frequent.     In  the  present  war  only  an  approximate  percentage 


224  ABSTRACTS  OF  WAR  SURGERY 

has  been  established.  Wounds  of  the  neck  may  be  taken  as  about 
3  per  cent  of  the  total  wounds.  In  an  experience  with  several 
thousand  wounded  the  author  has  found  only  about  30  wounds 
of  the  larynx  and  trachea. 

They  class  laryngotracheal  injuries  as  (1)  neuropathic  dis- 
turbances, (2)  extrinsic  or  extralaryngeal  lesions,  and  (3) 
lesions  of  the  laryngotracheal  region. 

In  the  second  category  the  author  gives  some  clinical  examples 
of  nerve  and  muscle  lesions  and  lesions  involving  the  esophagus. 
In  the  third  category  are  lesions  of  the  laryngeal  region  (cartilage, 
muscles,  articulations,  and  ligaments),  of  the  cricoid,  epiglottis, 
and  trachea. 

The  immediate  results  of  laryngotracheal  injuries  are  hemor- 
rhage, emphysema,  asphyxia,  and  sudden  death.  In  the  great 
majority  of  cases  of  penetrating  wounds  of  the  laryngotracheal 
tract,  the  respiration  was  compromised  to  such  an  extent  that 
tracheotomy  was  necessary  to  save  the  life  of  the  patient.  Be- 
sides this  preliminary  preventive  tracheotomy  the  wound,  as  is 
the  common  practice  in  all  war  injuries,  must  be  opened  up  and 
cleaned  and  foreign  bodies,  etc.,  removed.  These  procedures  of 
tracheotomy  and  cleansing  constitute  the  immediate  treatment 
of  such  injuries. 

The  results  consecutive  to  laryngotracheal  injuries  are  classed 
by  the  author  as  (1)  edema  of  the  laryngeal  mucosa;  (2)  sup- 
purations; (3)  inflammatory  stenoses;  (4)  paralyses.  Such  re- 
sults may  necessitate  a  second  tracheotomy.  This  should  be 
systematically  performed.  Intercricothyroidean  laryngotomy 
ought  never  be  done,  according  to  the  opinion  of  the  authors. 

A  large  portion  of  the  author's  extensive  article  is  devoted  to 
a  detailed  study  of  laryngotracheal  cicatricial  stenoses,  including 
(1)  circular  or  membranous  stenoses;  (2)  tubular  stenoses;  (3) 
complications ;  perichondritis,  .  etc. ;  and  the  treatment  by 
tracheolaryngostomy,  including  their  special  technic. 

Only  when  the  surgeon  is  quite  assured  that  cicatricial  retrac- 
tion has  terminated  and  that  laryngotracheal  permeability  is 
perfect  should  any  plastic  procedures  be  attempted. 

The  author  describes  the  detailed  technic  of  Moroi's  special 
laryngotracheal  autoplasty.  This  consists  in  making  two  cutane- 
ous flaps  around  the  laryngotracheal  opening  which  superimpose 
on  each  other  so  as  to  form  a  double  layer  over  the  opening. 

In  concluding  the  author  states  that  the  cicatricial  laryngeal 


ABSTRACTS  OF  WAR  SURGERY  225 

stenoses  of  war  are  quite  different  from  those  observed  in  peace 
and  the  prognosis  is  much  more  serious.  The  article  appears 
to  be  well  worth  careful  study  by  laryngologists. 

PENETRATING   WOUNDS    OF   THE   THORAX.— E.    Remond 
and  R.  Glenard.    Paris  med.,  1915,  v,  p.  450. 

The  authors  are  stationed  in  a  hospital  about  30  kilometers 
from  the  firing  line.  In  the  five  months  they  have  been  there 
they  have  treated  1,830  wounded  men,  150  of  them  being  wounds 
of  the  thorax,  in  110  of  which  the  projectiles  penetrated  the 
thoracic  wall.  About  three-fourths  of  these  patients  had 
hemoptysis,  a  much  higher  percentage  than  is  given  by  most 
authors;  but  absence  of  hemoptysis  does  not  necessarily  mean 
that  the  lung  is  uninjured.  Twelve  of  their  patients  died,  but 
in  6  of  them  there  were  severe  complications,  leaving  only  6 
fatalities  from  the  pulmonary  wound  alone. 

As  they  were  in  danger  of  having  to  move  their  quarters  at 
any  time  they  could  not  establish  an  x-ray  room,  but  there  was 
an  x-ray  carriage  that  could  be  summoned  and  reach  them  with- 
in twenty-four  hours,  so  that  they  were  able  to  locate  the  pro- 
jectiles in  a  number  of  cases,  and  extract  them  if  superficial. 
The  lung  complications  that  they  encountered  were  prolonged 
hemoptysis,  hemopneumothorax,  purulent  pleurisy,  pulmonary 
congestion,  bronchopneumonia,  simple  bronchitis,  and  abscess 
of  the  lung.  Aside  from  the  lung  complications  there  were  6 
cases  of  subcutaneous  emphysema,  3  cases  of  paralysis  of  the 
arm  from  injury  of  the  brachial  plexus,  and  a  number  of  cases 
of  abdominal  injury  and  fractures  of  various  bones. 

The  first  essential  in  treatment  is  to  place  the  patient  at  rest 
as  quickly  as  possible.  The  author's  patients  were  placed  in 
large,  well-aired  rooms,  not  more  than  two  in  a  room,  and  they 
were  cared  for  in  their  beds  to  avoid  moving  them  to  the  cen- 
tral dressing  room  that  was  used  for  other  kinds  of  wounds. 
No  probing  should  be  done  for  deep-seated  projectiles,  as  the 
lung  tolerates  their  presence  very  well,  and  there  is  danger  of 
both  infection  and  hemorrhage  from  probing. 

The  general  treatment  for  hemothorax  is  expectant;  puncture 
should  be  done  only  when  the  volume  of  the  effusion  threatens 
serious  complications  or  when  it  shows  signs  of  becoming  puru- 
lent. Such  operations  as  ligation  of  intrathoracic  vessels,  suture 
of  the  lung,  and  extraction  of  deep  projectiles  are  too  serious  to 


226  ABSTRACTS  OF  WAR  SURGERY 

be  undertaken  at  the  hospitals  at  the  front.  The  only  opera- 
tion that  has  to  be  performed  quite  frequently  is  rib  resection 
for  empyema.  If  a  hemothorax  is  accompanied  by  persistent 
fever  an  exploratory  puncture  should  be  made  and  if  pus  is 
found  operation  should  be  performed  at  once.  Patients  with  in- 
juries of  the  lung  should  not  be  transported  for  at  least  eight  days, 
even  though  they  are  apparently  well.  One  patient  was  sent  away 
after  five  days  and  he  died  of  secondary  hemorrhage  when  he 
reached  the  hospital  in  the  interior.  Some  of  the  patients  were 
obliged  to  stay  as  long  as  forty  days. 

GUNSHOT  WOUNDS  OF  THE  LARYNX  AND  TRACHEA.— K. 

Kofler,    and   V.    Fruehwald.      Wein.    klin.    Wchnschr.,    1915, 
xxviii,  p.  1337. 

The  authors  give  the  histories  of  one  case  of  injury  of  the 
trachea  and  16  cases  of  injury  of  the  larynx  which  they  have 
had  occasion  to  treat  in  their  hospital  in  the  home  zone.  A 
table  is  given  showing  the  treatment  and  results  in  each  case. 
The  symptoms  that  immediately  follow  a  wound  of  the  larynx 
are  more  or  less  severe  bleeding  and  the  expectoration  of 
blood  for  several  days,  and  in  some  cases  emphysema  of  the 
skin;  varying  degrees  of  hoarseness  to  complete  aphonia  and 
in  many  cases  increasing  difficulty  in  breathing.  Sometimes 
there  is  loss  of  consciousness  and  difficulty  in  swallowing.  The 
only  symptom  that  demands  immediate  attention  in  the  field 
is  difficulty  in  breathing,  for  which  the  field  surgeon  often  has 
to  do  tracheotomy  or  syndesmotomy.  Among  the  authors'  cases 
each  of  these  operations  had  been  performed  twice. 

The  symptoms  the  patients  complained  of  in  the  home 
hospital  were  perichondritis,  smooth  or  nodular  swellings  in 
the  larynx,  scars  and  cicatricial  adhesions  in  the  form  of  web- 
like membranes,  in  one  case  a  hematoma  that  recovered  spon- 
taneously and  speech  difficulties  due  to  nervous  or  inflammatory 
changes  of  the  cords.  Treatment  in  most  cases  was  expectant 
in  the  hope  that  the  condition  would  improve  with  the  dis- 
charge of  necrotic  bits  of  cartilage.  This  often  occurs  in  civil 
practice.  In  one  case  the  findings  in  the  larynx  and  the  voice 
did  improve  markedly  after  bits  of  cartilage  were  coughed  up. 
The  danger  that  such  bits  of  cartilage  may  fall  into  a  bronchus 
or  be  aspirated  is  slight.  In  three  cases  exuberant  granulations 
were  removed  with  sharp  forceps,  resulting  in  improvement 
in  breathing  and  speech.    Three  cases  were  dilated  with  bougies 


ABSTRACTS  OF  WAR  SURGERY  227 

or  dilators,  with  the  result  that  one  could  have  his  tube  re- 
moved and  be  discharged  with  normal  breathing  and  speech, 
while  the  other  two  are  still  under  treatment.  In  one  case  an 
adhesion  of  the  subglottic  space  was  removed  after  which  the 
laryngeal  findings  became  completely  normal.  Inhalations  and 
electricity  were  utilized  as  aids  in  treatment. 

Of  the  6  patients  who  had  tracheotomy  or  syndesmotomy 
performed,  only  2  still  wear  the  tubes,  while  the  other  4  have 
recovered  sufficiently  to  have  them  removed.  The  results  so 
far  as  the  voice  was  concerned  were  good  in  8  cases,  though 
some  of  these  were  very  severe  injuries.  In  some  cases  the 
patients  remained  aphonic,  while  in  one  case  the  voice  became 
deeper  and  in  one  case  speech  demands  considerable  effort. 

WAR  WOUNDS  OF  THE  LUNG.— Rev.  of  War  Surg,  and  Med., 
June,  1918,  i,  No.  4. 

In  recent  French  literature  there  are  two  particularly  valuable 
contributions  to  war  injuries  of  the  lung  by  Pierre  Duval  (Les 
Plaies  de  Guerre  du  Toumon,  Masson  et  Cie.,  Paris,  1917)  and  M. 
Piery  (Le  Poumon  de  Guerre,  Rev.  Gen.  de  Path,  de  Guerre,  1917, 
no.  5.  p.  509).  From  these  two  articles  mainly  the  following  col- 
lective abstract  has  been  built  up.  Other  data  bearing  on  lung 
injuries  will  be  appended  in  the  form  of  separate  abstracts. 

Clinical  Aspects  of  Lung  Wounds. — Piery  points  out  that 
whereas  before  the  war  surgeons  approached  the  lung  in  a 
more  or  less  timid  fashion,  they  have  become  bold  and  sure 
as  a  result  of  a  recent  experience  gained  by  them  in  war  sur- 
gery. 

Practically  all  war  wounds  are  caused  by  projectiles  of  one 
sort  or  another — very  few  stab  wounds  are  described  up  to 
date.  These  projectile  wounds  can  best  be  considered  under 
the  following  five  heads:  (1)  Simple  chest  wounds  with  hemo- 
pleuro-pneumonic  symptoms;  (2)  complicated  chest  wounds; 
(3)  etiological  and  pathological  factors;  (4)  symptomatology  of 
chest  wounds;    (5)  treatment   of  chest  wounds. 

Under  the  first  head  of  simple  chest  wounds,  Piery  says  the 
really  striking  thing  is  the  fact  that  simple  war  wounds  are 
practically  always  accompanied  by  a  definite  symptom  com- 
plex, the  only  variation  being  in  the  intensity  and  duration  of 
the  symptoms.  This  symptom  complex  he  has  called  syndrome 
hemo-pleuro-peumonique,  because  anatomically  it  is  character- 
ized by  hemothorax  with  an  accompanying  pneumonia. 


228  ABSTRACTS  OF  WAR  SURGERY 

There  is  the  first  shock  immediately  followed  by  dyspnea, 
both  of  varying  intensity,  and  followed  in  turn  by  more  or  less 
inconstant  hemoptysis,  rarely  profuse.  The  following  day  there 
appear  physical  signs  that  are  quite  striking  in  their  constancy. 
Over  the  lower  third  of  the  lung  posteriorly  there  is  flatness, 
absence  of  voice  sounds,  absence  of  or  diminished  breath  sounds ; 
from  the  middle  third,  dullness,  with  normal  or  exaggerated 
voice  and  tubular  or  almost  tubular  breathing. 

The  radioscopic  examination  shows  a  large,  dark  shadow  re- 
placing the  clear  lung  area  ordinarily  seen  under  normal  cir- 
cumstances, which  extends  over  the  lower  two-thirds  of  the 
wounded  lung.  This  shadow  fades  out  gradually,  with  no 
tendency  to  demarcation  into  two  zones.  This  x-ray  examina- 
tion may  also  disclose  a  projectile. 

Exploratory  aspiration  (indispensable  in  these  cases)  con- 
firms the  diagnosis.  A  cell  count  of  the  aspirated  fluid  shows: 
(a)  A  gradually  rising  polymorphonuclear  leucocytosis — de- 
fense against  infection — during  the  first  five  or  seven  hours, 
followed  by  (b)  a  drop  in  the  number  of  leucocytes,  due  to 
dilution  of  the  blood  and  lasting  4  to  30  hours,  followed  by 
(c)  increase  in  leucocytosis,  but  chiefly  of  the  eosinophiles  and 
mononuclears.  This  last  phase  ushers  in  the  stage  of  absorp- 
tion and  lasts  8  to  20  hours. 

Hemoptysis  (immediate,  delayed,  and  secondary),  cough,  and 
dyspnea  require  no  special  description.  The  elevation  of  tem- 
perature which  occurs  in  these  cases  merits  special  mention  be-, 
cause  it  is  one  of  the  most  characteristic  symptoms.  It  begins 
within  12  to  24  hours,  and  then  after  the  third  or  fifth  day 
maintains  a  height  of  from  101.5°  F.  to  102.5°  F.  for  about  15 
days.  Defervescence  occurs  by  lysis  and  is  usually  completed 
in  about  three  weeks. 

These  cases  may  clear  up  completely,  the  physical  signs  or 
remnants  of  them  existing  from  three  to  five  weeks,  the  pa- 
tient, however,  being  in  good  physical  condition;  or  the  patient 
may  become  seriously  ill,  with  marked  elevation  of  temperature, 
lasting  from  four  to  six  weeks  and  unaccompanied  by  any 
confirmatory  evidence  of  empyema  or  other  complications.  This 
fever  is  due  to  pneumonia,  and  it  is  for  this  reason  that  Piery 
uses  the  phrase  syndrome  hemo-pleuro-pneumonique.  He  also 
insists  that  the  temperature  is  due  to  pneumonia,  even  though 
typical  symptoms  be  absent  and  physical  signs  not  in  evidence. 
Cases  of  this  type  will  frequently  drag  along  from  six  to  eight 
weeks. 


ABSTRACTS  OF  WAR  SURGERY  229 

The  significant  fact  is  that  both  the  mild  and  severe  cases  of 
simple  lung  wounds  (provided  there  are  no  complications)  always 
terminate  favorably.  Piery  treated  25  patients  with  simple  pene- 
trating wounds,  with  a  100  per  cent  recovery.  This  does  not  mean 
that  there  is  complete  restitutio  ad  integrum.  About  one-third 
of  the  patients  develop  recurrent  bronchitis,  and  many  of  them 
have  more  or  less  persistent  chest  pains,  dyspnea  on  effort,  dry 
cough,  and  general  irritability  over  quite  a  long  period  of  time. 
All  in  all,  however,  over  50  per  cent  of  the  patients  lead  ac- 
tive lives  and  are  fit  for  army  duty. 

Under  the  head  of  complications  of  penetrating  wounds  of 
the  lung,  we  have  to  consider  immediate  and  remote  complica- 
tions. Immediate  complications  are  fairly  well  understood, 
having  been  well  described  by  the  medical  men  at  the  front. 
The  remote  complications,  seen  mostly  by  the  personnel  of  the 
base  interior  hospitals,  have  been  less  accurately  described. 

Of  the  immediate  complications,  the  three  most  important 
are:  (1)  Pneumothorax,  (2)  secondarily  infected  hemothorax, 
(3)   primary  pyopneumothorax. 

Pneumothorax  is  extremely  frequent,  occuring  in  about  47 
per  cent  of  the  cases  seen  by  Piery.  A  striking  fact  is  the 
frequency  with  which  partial  pneumothorax  occurs  without 
playing  any  part  whatever  from  the  point  of  view  of  symp- 
tomatology. As  a  rule,  pneumothorax  is  due  to  the  escape  of 
air  from  the  lung  parenchyma.  Much  more  serious  is  the  type 
of  pneumothorax  due  to  a  gaping  wound  of  the  chest  wall. 
This  type  of  pneumothorax  is  almost  always  total,  and  almost 
always  results  in  infecting  the  pleural  cavity,  setting  up  acute 
empyema. 

The  secondarily  infected  hemothorax  occurred  in  about  13 
per  cent  of  Piery 's  cases,  and  manifested  itself  by  a  recurrence 
of  fever  about  the  third  or  fourth  week.  Exploratory  aspira- 
tion serves  to  differentiate  this  condition  from  the  fresh  pneu- 
monia. It  is  unnecessary  to  add  that  this  condition  is  much 
more  serious  than  is  pneumothorax. 

Primary  pyopneumothorax  may  be  partial  or  total.  The  par- 
tial ones  are  very  difficult  to  diagnosticate.  X-ray,  however, 
aids  a  great  deal  in  reaching  a  conclusion  concerning  them, 
and  exploratory  aspiration  is  invaluable. 

Total  pyopneumothorax  occurs  usually  with  severe  infections 
of  the  pleura  and  is  always  of  grave  prognostic  import. 

Under  the    head    of  remote    complications  we    must  group: 


230  ABSTRACTS  OF  WAR  SURGERY 

(1)  Late  hemoptysis,  (2)  abscess  of  the  lung,  (3)  gangrene  of 
the  lung,  (4)  late  pneumonia,  (5)  accidents  which  are  followed 
by  rapid,  sudden,  unexplained  death,  possibly  related  to  those 
cases  which,  in  civil  practice,  have  been  grouped  under  the 
head  of  "Accidents  due  to  pleura  reflex." 

Mortality  of  War  Wounds  of  the  Lung1. — Duval  has  collected 
3,453  cases  of  lung  wounds  reported  by  37  different  surgeons, 
showing  a  mortality  of  20  per  cent.  This  mortality  varies  in 
the  different  formations.  At  the  Regimental  Aid  Station  the 
mortality  is  very  high,  25  to  30  per  cent  being  the  figures  usually 
given.  During  the  early  days  of  the  war  one  authority  is 
quoted  as  having  said  that  at  the  front  all  cases  of  grave  in- 
juries of  the  lung  died.  Hemorrhage  and  asphyxia  due  to 
mechanical  interference  with  respiration  are  the  two  principal 
causes  of  death.  In  the  surgical  automobile  ambulance  sta- 
tions the  mortality  has  been  from  18  to  20  per  cent.  In  the 
hospitals  of  the  line  of  communication  the  mortality  falls  in 
a  general  fashion  to  about  10  or  12  per  cent,  thus  demonstrat- 
ing that  the  mortality  of  injury  to  the  lungs  diminishes  pro- 
portionately with  the  distance  from  the  front.  The  rule  in  the 
French  Army  is  to  consider  all  chest  wounds  as  not  transport- 
able, and  to  hold  them  permanently  at  the  first  hospital  in  the 
line  of  formation  that  is  equipped  to  receive  them.  For  this 
reason,  there  arrive  at  the  more  distant  hospitals  only  those 
lung  cases  which  are  in  very  good  physical  condition. 

As  a  general  broad  figure,  one-half  of  the  chest  cases  die 
in  the  first  few  days  after  reception  of  injury.  Duval  is  ex- 
plicit in  his  statement  that  in  these  deaths  he  does  not  include 
fatalities  due  to  empyema,  abscess  of  the  lung  or  to  other  late 
complications,  and  he  is  equally  emphatic  on  the  stress  that 
he  lays  on  this  high  mortality  rate,  which  he  characterizes  as 
"frightful  and  stupefying  to  a  degree  not  even  suspected  be- 
fore this  war."  The  fact  that  in  civil  life  gunshot  wounds  of 
the  chest  were  originally  looked  upon  as  particularly  benign 
is  explained  on  the  basis  that  these  civil  wounds  are  almost 
always  the  result  of  bullets.  A  large  proportion  of  wounds  of 
war  are,  on  the  contrary,  due  to  artillery  projectiles.  Depage 
noted  a  mortality  of  17.6  per  cent  after  bullet  wound  and  26.8 
per  cent  after  shell  wound.  The  bullet  wounds  are  either  im- 
mediately fatal  as  a  result  of  grave  vascular  injury,  or  else 
they  are  relatively  benign.  They  are  attended  by  very  few 
late  complications,  and,  on  the  whole,  are  innocuous.  All  this 
is  in  marked  contrast  to  wounds  caused  by  artillery  projectiles. 


ABSTRACTS  OF  WAR  SURGERY  231 

In  the  case  of  artillery  projectiles,  the  mortality  rate  depends 
in  large  measure  on  whether  the  shell  fragment  completely 
traverses  the  lung  or  whether  it  remains  imbedded  in  it,  as  a 
foreign  body.  Duval  determined  in  the  first  instance  a  mor- 
tality of  21  per  cent,  which  in  the  second  instance  was  raised 
to  30  per  cent.  Furthermore,  the  mortality  varies  with  the 
length  of  time  elapsing  after  the  injury.  About  50  per  cent 
characterizes  the  mortality  of  the  first  day — about  60  per  cent 
of  the  first  two  days.  Furthermore,  we  have  to  consider  the 
wound  in  the  chest  wall  itself;  a  so-called  open  thorax  (that  is, 
gaping  wound  in  the  chest  wall)  is  attended  by  almost  twice 
as  high  a  mortality  as  occurs  after  the  closed  wound. 

On  the  topic  of  mortality  Piery  says  that  the  prognosis  of 
the  simple,  penetrating  wound  is  very  much  better,  as  regards 
life,  than  one  would  be  led  to  imagine.  In  Piery 's  experience, 
wounds  of  this  type  have  been  attended  by  far  better  results 
than  wounds  of  the  femur,  and,  on  the  whole,  have  been  aston- 
ishing in  their  benignancy.  His  mortality  has  been  9.4  per  cent, 
the  mortality  of  Maissonet  20  per  cent,  and  that  of  Depage  and 
Jannsen  15.3  per  cent.  Piery  emphasizes  that  in  speaking  of 
this  low  mortality  rate  he  is  considering  only  the  simple,  pene- 
trating wounds  of  the  chest  and  not  those  serious  accidents  ac- 
companied by  injury  to  the  heart  and  large  vessels.  Another 
interesting  fact  is  that  pneumothorax,  not  even  the  total 
pneumothorax,  seems  to  influence  the  prognosis  unfavorably. 
Indeed,  pneumothorax  may  be  looked  upon  as  a  beneficial  symp- 
tom in  that  it  compresses  the  lung  and  checks  bleeding.  The 
two  gravest  prognostic  elements  are  the  large,  open  chest 
wound  and  generalized  infection.  It  is  well  to  call  attention 
to  the  significance  of  the  pulse  in  prognosis.  Piery  stating 
that  a  pulse  which  alters  from  about  100  beats  to  the  minute 
to  a  rate  of  120  to  130  with  slight  irregularity,  is  a  sign  of  the 
gravest  possible  significance. 

Mortality  of  Lung  Wounds  (Duval)  (based  on  3,453  Cases). 

Per  cent. 
Total  mortality  rate 20 

Mortality  in  the  various  zones : 

Regimental  aid 25 

Ambulance  divisions  and  evacuation  hospitals . .  20 
Lines  of  communication  hospitals 10 


232  ABSTRACTS  OF  WAR  SURGERY 

Mortality  according  to  nature  of  projectile : 

Bullet  wounds 5-15 

Shells    25 

Mortality  according  to  nature  of  wound : 

Through-and-through 21 

Eetained   foreign  body 30 

Closed  thorax 15 

Open  gaping  thorax 27 

Mortality  according  to  time  interval : 

Mortality  during  first  24  hours 32-50 

Mortality  during  first  48  hours 60 

Pathological  Anatomy  of  Lung  Wounds. — Wounds  of  the  lung 
present  themselves  as  (a)  through-and-through  wounds;  (b) 
wounds  of  the  surface;  (c)  tunnel  wounds.  Bullet  wounds  need 
very  little  consideration,  because  they  very  rarely  call  for  opera- 
tive interference. 

The  through-and-through  wound  caused  by  shell  fragment 
is  sometimes  clean-cut  and  regular.  If  the  shell  fragment  is 
large,  the  wound  may  be  very  irregular,  with  numerous 
branches,  the  point  of  exit  being  larger  than  the  point  of  en- 
try. The  two  serious  lesions  characterizing  this  type  of  in- 
jury are  the  destruction  of  pulmonary  tissue  and  the  accom- 
panying hemorrhagic  infiltration  in  the  region  about  the  wound. 
All  lung  wounds  are  made  up  of  cellular  necrosis  more  or  less 
extensively  combined  with  the  parenchymatous  destruction 
which  is  seen  in  all  the  wounds  of  other  soft  parts.  The  tis- 
sue immediately  surrounding  the  wound  is  dead  and  cold,  with 
only  slight  tendency  toward  crepitation.  The  vascularity  of 
the  lung  explains  the  hemorrhagic  infiltration;  one  wonders  why, 
in  such  richly  vascular  tissue,  severe  hemorrhages  are  not  even 
more  frequent. 

Wounds  of  the  lung  may  or  may  not  contain  projectiles,  and, 
what  is  even  more  important,  they  may  contain  other  foreign 
bodies  such  as  pieces  of  clothing.  It  is  important  to  bear  in 
mind  that  these  foreign  bodies  may  be  retained  in  the  lung, 
even  though  the  projectile  has  passed  completely  through  and 
out.  Another  type  of  foreign  body  of  importance  is  the  bone 
fragment  carried  in  from  fractured  ribs.  These  fragments  are 
particularly  dangerous,  both  primarily  and  as  the  cause  of  later 
complications.  These  bone  fragments  almost  always  cause  bone 
suppuration  and  a  very  grave  type  of  pleuropneumonia.     The 


ABSTRACTS  OF  WAR  SURGERY  233 

development  pathologically  of  a  lung  wound  is  in  reality  the 
same  as  that  of  all  other  war  wounds.  They  are  from  the 
outset  contaminated  by  the  foreign  body  which  created  them, 
and  they  present  a  more  or  less  marked  degree  of  necrosis, 
which  serves  as  a  culture  medium  for  the  infection,  which  de- 
velops within  a  certain  number  of  hours  after  the  infliction  of 
the  injury.  Anatomically,  lesions  are  the  same,  the  infected 
foreign  bodies  the  same,  the  types  of  bacteria  the  same,  and 
the  biological  development  the  same.  On  these  important  facts, 
proper  treatment  of  war  wounds  of  the  lung  rests. 

An  interesting  factor  in  these  injuries  is  the  disturbance 
which  occurs  at  quite  some  distance  from  the  injured  side, 
sometimes  even  in  the  opposite  lung.  These  lesions  have  some- 
times been  termed  "conlre-coup."  The  opposite  King  is  not  infre- 
quently the  seat  of  marked  congestion  or  purulent  pleurisy. 

Treatment  of  War  Wounds  of  the  Lung. — Treatment  is 
divided  under  the  heads  of  immediate  treatment,  consecutive 
treatment,   and  treatment  for  complications. 

Immediate  treatment  has  to  do,  in  the  first  place,  with  assur- 
ing the  wounded  man  rest  during  transport,  treatment  at  the 
regimental  aid  station  and  at  the  evacuation  hospital.  Trans- 
port over  any  appreciable  distance  is  contraindicated.  After 
application  of  the  first-aid  dressing,  one  limits  his  efforts  to 
combating  the  tendency  to  collapse,  the  dyspnea  and  pain 
(morphine).  As  a  matter  of  fact,  the  chest  should  be  im- 
mobilized on  the  injured  side,  but  Piery  says  that  one  should 
not  worry  if  the  immobilization  is  not  very  thorough,  because 
there  are  few  bad  effects  caused  by  transport  over  ordinary 
distance. 

Copious  hemorrhages  of  a  very  threatening  nature  are  from 
the  very  outset  hopeless.  This  does  not  mean,  however,  that 
nothing  should  be  attempted  in  the  way  of  hemostasis  for  im- 
mediate hemorrhage  in  lung  wounds.  Last  year  the  Societe  de 
Chirurgie  was  divided  into  two  schools,  one  group  of  men 
feeling  that  nothing  could  be  done  in  these  early,  grave  in- 
juries, another  group  thinking  that  since  they  were  practically 
all  fatal  if  untried,  some  attempt  should  be  made  at  hemostasis. 
Duval  agrees  with  those  surgeons  who  believe  that  in  certain 
cases  of  single  massive  pulmonary  hemorrhage,  operative  inter- 
ference saves  the  patient,  and  refusal  to  operate  causes  the  loss 
of  a  patient  who  might  otherwise  have  been  saved.  The  high 
mortality  of  60  per  cent  during  the  first  two  days  after  the 
injury  is    probably    accounted  for    largely  by    these  massive, 


234  ABSTRACTS  OF  WAR  SURGERY 

acute  hemorrhages.  Reports  by  Sencert,  Gatallier,  Latarget,  de 
Beyre  and  others,  all  confirm  this  fact,  and  they  all  in  a  meas- 
ure  justify   an   emergency  hemostatic   operation. 

These  hemorrhages  occur  in  two  types:  (a)  Immediate;  (b) 
late.  The  immediate  type  requires  no  lengthy  explanation.  It 
may  be  external,  or  purely  intrapleural.  The  intrapleural 
variety  does  not  cause  death  as  frequently  as  does  the  open 
hemorrhage,  because  the  imprisoned  blood  causes  compression 
of  the  injured  lung.  It  must  not  be  forgotten,  however,  that 
although  compression  of  the  lungs  checks  hemorrhage,  and 
checks  it  with  a  degree  of  certainty  proportional  to  the  degree 
of  compression,  yet  nevertheless  this  is  not  entirely  a  beneficient 
factor,  for  this  very  pressure  may  mechanically  affect  the  op- 
posite lung  and  the  heart,  and  thus  indirectly  prove  fatal. 

Certain  cases  of  hemorrhage  do  not  seem  to  prejudice  the 
patient  at  first,  but  later,  after  transport,  the  patient  collapses 
and  dies,  or  the  same  unfortunate  result  occurs  during  trans- 
port. The  explanation  of  this  fact  is  that  either  a  steady,  slow 
hemorrhage  exsanguinates  the  patient,  or  bleeding  which  had 
spontaneously  ceased  is  set  up  again  as  a  result  of  the  transport. 
It  is  for  this  reason  that  Depage,  Duval,  and  others  recommend 
the  so-called  emergency  operation  for  checking  hemorrhage 
even  at  the  front.  The  practical  disadvantage  connected  with 
this  advice  is  the  difficulty  of  determining  which  cases  should 
be  operated  on.  The  differential  diagnosis  between  shock  and 
hemorrhage  is  a  very  difficult  one  to  establish,  and  many  of 
the  patients  with  chest  injuries  are  in  profound  shock.  It  is 
true  that  the  early  operation  for  severe  hemorrhage  rescues 
the  wounded  man  from  death,  but,  on  the  other  hand,  if  opera- 
tive interference  be  instituted  on  false  grounds,  no  hemorrhage 
existing,  and  if  death  ensues,  it  may  properly  be  placed  at  the 
door  of  unnecessary  operation.  Duval  himself  characterizes 
this  problem  as  an  agonizing  one.  Should  one  rather  allow  a 
wounded  man  to  die  without  furnishing  surgical  aid,  or  should 
one  resort  to  an  emergency  operation  carrying  with  it  the 
gravest  dangers?  It  is  the  need  of  answering  this  question, 
again  to  quote  Duval,  that  weighs  most  heavily  on  the  con- 
science of  the  surgeon  working  at  the  front. 

The  problem  may  in  part  be  solved  by  dividing  the  patients 
into  two  groups :  In  the  first  group  belong  the  wounded  who 
arrive  at  a  field  hospital  with  a  grave,  initial,  or  late  hemor- 
rhage. In  this  type  of  patient,  emergency  operation  is  indicated, 
"For  in  some  part  of  the  lung  there  is  a  blood  vessel  which 


ABSTRACTS  OF  WAR  SURGERY  235 

must  be  tied"  (Terrier).  In  the  second  group,  the  hemorrhage 
is  partly  intrapleural  and  menaces  the  life  of  the  patient,  not 
so  much  as  a  result  of  blood  loss  as  by  the  compression  of  the 
heart  and  lungs.  In  this  group  of  cases  it  is  essential  to  ob- 
serve the  patients  over  a  period  of  time.  Frequent  examina- 
tions should  be  made,  always  with  the  caution  in  mind,  how- 
ever, not  to  disturb  the  patient  unduly.  Radioscopy,  it  must 
be  borne  in  mind,  is  of  very  little  use  in  these  cases,  unless  the 
patients  are  examined  in  a  sitting  posture.  Aspiration  of  the 
chest  is  a  valuable  aid.  It  used  to  be  thought  that  the  coagula- 
tion of  aspirated  blood  indicated  progressive  hemorrhage, 
whereas  conversely,  failure  to  coagulate  indicated  that  the 
hemorrhage  had  ceased.     This,  however,  is  not  true. 

In  these  doubtful  cases,  the  entire  surface  of  the  patient's 
body  should  be  kept  warm,  and  every  half  hour  the  blood  pres- 
sure should  be  taken.  During  this  period  the  head  of  the  pa- 
tient should  not  be  depressed,  and  he  should  receive  no  intraven- 
ous saline.  If  the  pressure  steadily  falls,  it  means  that  the 
patient  is  bleeding,  and  if  one  has  been  able  to  determine  this 
fact  with  a  fair  degree  of  assurance,  he  may  proceed  on  the 
basis  that  direct  hemostasis  of  the  lung  wound  is  a  veritable 
operation  of  salvation.  Duval  has  done  this  without  an  anes- 
thetic in  cases  that  seemed,  in  every  sense  of  the  word,  desper- 
ate, and  he  is  inclined  to  draw  the  conclusion  that  so  long  as 
these  cases  of  hemorrhage  are  not  dead  one  ought  to  try  to 
save  them  by  operation.  This  is  particularly  true  in  view  of 
the  fact  that  the  operation  has  no  effect  in  blood  pressure  and 
may  be  performed  in  the  face  of  a  pressure  which  would  ab- 
solutely contraindicate  any  type  of  abdominal  operation.  In 
21  cases  of  this  sort,  which  were  formidably  grave,  Duval  suc- 
ceeded in  attaining  a  cure  in  70.6  per  cent. 

Infection  in  Wounds  of  the  Lung". — The  very  nature  of  lung 
war  wounds  caused  by  artillery  is  such  that  they  carry  the 
same  type  of  infection  that  one  meets  in  all  other  war  wounds. 

Wounds  caused  by  bullets  are  very  frequently  sterile,  al- 
though they  are  not  infrequently  followed  by  pulmonary  con- 
gestion, a  mild  pleuropneumonia,  or,  rarely,  by  a  more  or  less 
severe  suppurating  hemothorax. 

Small  shell  fragment  wounds,  provided  they  are  not  com- 
plicated by  bits  of  clothing,  are  also  frequently  sterile.  The 
pulmonary  wound  is  in  this  instance  rapidly  closed  by  the  col- 
lapse of  the  lung  and  by  the  layer  of  fibrin  which  covers  the 
lung,  thus  protecting  the  pleural  cavity  against  infection.    The 


236  ABSTRACTS  OF  WAR  SURGERY 

pulmonary  congestion  which  usually  results  is  to  be  construed 
as  a  parenchymatous  reaction  on  the  part  of  the  lung  rather 
than  as  a  microbie  infection.  A  microscopic  examination  of 
the  sputum  shows  the  ordinary  intrapulmonary  bacteria. 

Wounds  caused  by  larger  shell  fragments  are  practically  al- 
ways followed  by  a  grave  type  of  infection  due  to  anaerobes. 
This  is  particularly  true  if  a  bone  splinter  has  been  driven  into 
the  lung.  The  infection  may  develop  in  the  lung  itself,  in  the 
hemothorax  or  in  the  opposite  lung.  If  the  hemothorax  is  of 
large  volume,  the  lung,  which  is  totally  collapsed,  does  not 
readily  become  infected,  the  hemothorax  itself  bearing  the 
brunt  of  bacterial  infection.  If,  on  the  other  hand,  the  hemo- 
thorax is  small  in  quantity  and  the  lung  not  in  total  collapse, 
or  if  old  adhesions  prevent  collapse  of  the  lung,  then  we  are 
more  apt  to  have  pulmonary  infection  in  the  form  of  broncho- 
pneumonia, septic  pneumonia,  abscess  of  the  lung,  or  gangrene 
of  the  lung. 

Owing  to  the  large  amount  of  oxygen  in  the  lung  substance, 
there  is  only  a  slight  tendency  for  the  gas  bacillus  to  develop 
to  its  usual  full  extent,  and  Duval  says  that  in  his  autopsies  he 
has  rarely  seen  a  case  of  lung  gangrene  which  he  could  say 
positively  was  gas  gangrene.  The  hemothorax  itself,  ac- 
cording to  Elliot  and  Henry,  who  analyzed  500  cases,  was  in- 
fected 195  times.  In  these  195  instances,  87  were  traceable  to 
anaerobes.  Pneumococci,  staphylococci,  tetragenus,  bacillus  of 
Pleiffer,  streptococci,  colibacillus,  prefringens,  and  sporogenes 
were  found  in  the  course  of  routine  bacteriological  examina- 
tion. The  general  statement  therefore  holds  true  that  the 
hemothorax  is  infected  by  the  transport  into  it  of  the  differ- 
ent varieties  of  anaerobes,  and  aerobes,  with  the  projectile.  If 
the  thorax  presents  a  large,  gaping  wound,  then  we  have  in 
addition  the  infection  that  is  carried  in  from  the  external  air. 

Infection  of  the  hemothorax  leads  to  a  hemopyopneumothorax 
either  free  or  loculated,  always  grave  and  often  fatal.  In  ad- 
dition to  this  type  of  infection,  we  have  to  bear  in  mind  al- 
ways the  possibility  of  a  generalized  systemic  infection. 

Knowing  what  we  do  regarding  the  resistance  of  the  lung 
against  the  development  of  anaerobes  (we  can  not  say  posi- 
tively whether  this  resistance  is  due  to  an  abundant  supply  of 
oxygen,  a  high  degree  of  vascularization,  or  to  total  collapse 
of  the  lung),  it  is  not  illogical  to  close  a  penetrating  wound  of 
the  lung  at  both  these  extremities.  In  doing  this,  with  fair 
success,  we  protect  the  pleura  against  infection. 


ABSTRACTS  OF  WAR  SURGERY  237 

Operative  Indications. — Duval  was  among  the  first  to  assert 
that  one  should  treat  wounds  of  the  lung  from  the  very  outset 
just  as  he  treats  wounds  of  the  soft  parts  elsewhere.  He  based 
this  statement  on  the  fact  that  the  mortality  from  untreated 
lung  wounds  was  so  very  high  and  had  so  successfully  resisted 
the  application  of  all  other  than  operative  treatment.  Infec- 
tion and  hemorrhage  are  the  prime  factors  of  danger,  and  the 
type  of  injury  differs  very  little  from  injuries  of  the  soft 
parts.  In  other  words,  the  lesions  in  the  lung  and  in  the  soft 
parts  are  similar — the  bacteriology  is  identical — the  patholog- 
ical course  is  identical,  the  same  type  of  foreign  bodies  have 
to  be  reckoned  with,  and  the  consequences  are  the  same. 
Furthermore,  it  is  well  known  that  although  the  lung  tissue 
resists  infection  better  than  most  of  the  soft  tissue,  too  much 
reliance  should  not  be  put  on  this,  because,  although  the  lung 
resists  fairly  well,  the  pleura  has  a  low  grade  of  resistance. 

Since  it  is  an  accepted  principle  of  war  surgery  that  prohphy- 
lactic  surgical  treatment  is  the  best  type  of  treatment,  it  be- 
comes necessary  to  institute  surgery  in  injuries  of  the  lung  very 
early  if  one  hopes  to  accomplish  the  necessary  prophylactic 
measures.  As  a  matter  of  fact,  almost  up  to  the  present  time 
the  lung  has  been  the  sole  organ  which  has  not  been  subjected 
to  the  ordinary  rules  of  war  surgery.  Even  in  the  presence 
of  severe  hemorrhage  which  could  be  checked  by  ligation,  the 
lung  has  not  been  attacked  as  often  as  it  should  be.  The  seri- 
ousness of  operative  interference  has  been  urged  as  an  argu- 
ment against  radical  lung  surgery,  but  this  argument  will  not 
hold,  because  during  this  war  facts  have  developed  which  have 
occasioned  a  veritable  revolution  in  this  field.  Among  other 
things,  it  has  been  shown  that  the  fear  of  pneumothorax  dur- 
ing operation  is  unfounded,  and  that  without  any  particular 
danger,  one  may  perform  a  large  thorocotomy  or  eventrate  the 
lung,  lobe  by  lobe,  just  as  one  does  loops  of  intestines,  palpate, 
incise,  resect,  and  then  replace  it  in  the  thorax.  The  lung  is 
not  the  redoubtable  organ  that  it  was  before  the  war. 

In  discussing  operative  indications,  Piery  sounds  a  moderate 
note  of  conservation  when  he  points  out  that  he  considers  it 
unfortunate  that  the  early  optimistic  reports  regarding  the 
safety  of  lung  surgery  must  in  a  measure  be  modified — in  other 
words,  one  must  bear  in  mind  that  surgery  of  the  lung,  in 
spite  of  the  remarkable  recent  advance,  is  still  surgery  of  a 
very  grave  sort.     For  this  reason,  largely,  Piery  states  that  we 


238  ABSTRACTS  OF  WAR  SURGERY 

have  no  right  to  assume  that  every  foreign  body  in  the  lung 
must  of  necessity  be  extracted.  We  should  rather  base  the 
need  of  removal  on  some  complication  of  menace  referable 
directly  to  the  foreign  body.  The  most  urgent  indication  is 
hemorrhage.  Pulmonary  abscess  is  another  indication.  Fin- 
ally, there  is  to  be  determined  the  important  fact  as  to  whether 
pneumonic  process  is  dependent  on  the  foreign  body. 

Duval  emphasizes  the  necessity  of  determining:  (1)  How 
should  one  extract  a  projectile  from  the  lung?  (2)  Is  it  neces- 
sary to  treat  the  lung  wound  itself,  and  how?  (3)  What  is 
the  best  moment  to  institute  operative  intervention? 

It  may  be  considered  as  definitely  certain  that  the  mere  re- 
moval of  the  retained  projectile  is  in  itself  insufficient.  All 
other  foreign  bodies  must  be  removed  at  the  same  time.  The 
projectile  itself  may  be  removed  by  forceps,  but  if  it  has  pene- 
trated almost  completely  through  the  lung,  it  may  be  extracted 
after  having  made  an  incision  directly  over  it. 

As  regards  treating  the  wound  of  the  lung,  it  may  be  said 
that  the  ideal  treatment  is  excision.  For  various  reasons,  this 
can  not  always  be  done.  When  it  can  not  be  done,  the  tract 
of  the  wound  is  cleansed,  with  a  strip  of  gauze,  which  in  its 
removal  will  bring  with  it  fragments  of  metal  and  clothing  as 
well  as  tesselated  necrotic  lung  tissue.  After  this  cleansing,  the 
pleural  orifice  or  orifices  (if  it  is  a  through-and-through  wound) 
are  sutured  in  order  to  protect  the  pleura  against  infection. 
Duval  says  that  it  is  not  illogical  to  close  the  openings  of  a 
lung  wound,  thus  protecting  the  pleura  and  allowing  the  lung 
itself  to  combat  the  infected  material  which  may  have  been 
left  in  the  wound  after  all  foreign  bodies  have  been  removed. 
The  wound  toilet  should  not,  of  course,  be  considered  complete 
without  the  thorough  cleansing  with  the  strip  of  gauze  before 
closure  of  the  orifice.  When  the  wound  is  near  the  surface, 
excision  should  be  considered  as  ideal  treatment. 

Kegarding  the  opportune  moment  for  instituting  operative 
intervention,  it  is  frankly  admitted  that  a  conclusion  can  be 
reached  only  after  much  thought.  Immediate  intervention  is 
to  be  recommended  above  all,  but  only  after  due  account  has 
been  taken  of  the  general  condition  of  the  patient.  These  lung 
injuries  are  frequently  quite  shocking,  and  it  becomes  neces- 
sary to  afford  the  patient  more  rest  and  warmth  and  to  com- 
bat the  shock  before  operating  on  the  lung.  It  is  apparently 
true  that  the  operative  attack  on  the  lung  is  not  accompanied 
by  the  depressing  factors  that  attend  laparotomy.     Just  as  it 


ABSTRACTS  OP  WAR  SURGERY  230 

would  be  dangerous,  however,  to  rush  in  too  hurriedly,  so,  un- 
fortunately, it  would  be  equally  perilous  to  wait  too  long.  The 
septic  reaction  of  the  lung  after  injury  is  notoriously  rapid, 
even  more  so  than  that  of  the  pleura.  The  lung  passes  through 
a  period  of  asepsis,  just  as  do  the  soft  parts,  the  period  during 
which  they  are  contaminated,  though  not  infected.  It  is  dur- 
ing this  period  that  we  may  operate  with  most  favorable  out- 
look. 

In  all  attempts  to  reach  a  conclusion  regarding  operative 
interference,  one  should  bear  in  mind  that  wounds  from  bul- 
lets should  be  placed  in  a  group  by  themselves ;  because,  aside 
from  urgent  hemorrhage,  they  only  exceptionally  justify  opera- 
tive interference,  and  their  healing  is  usually  without  compli- 
cations. This  same  statement  may  hold  true  for  very  small 
shell  fragment  wounds,  but  when  we  come  to  deal  with  wounds 
caused  by  larger  shell  fragments,  we  may  say  with  assurance 
that  the  complicating  septic  pleuropneumonia  is  the  rule. 

In  those  wounds  occupying  a  place  between  the  innocent  bul- 
let wounds  and  the  very  grave  shell  wounds,  it  is  almost  im- 
possible to  establish  definite  operative  indications  broad  enough 
to  meet  all  needs. 

Even  at  the  risk  of  adding  an  element  of  confusion,  it  is  well 
to  add  the  counsel  of  Piery  regarding  the  proper  time  to  in- 
stitute operative  interference  for  the  removal  of  foreign  bodies : 
"The  best  time  to  operate  is  in  the  so-called  interval  after  the 
hemopleuropneumonia  has  abated.  Piery  says  that  the  situa- 
tion is  very  much  the  same  as  the  one  confronting  the  surgeon 
in  cases  of  appendicitis,  where  it  is  always  desirable  to  operate 
in  the  interval  if  possible,  or  where  the  surgeon  should  never 
hesitate  to  allow  his  hand  to  be  forced  by  threatening  symp- 
toms. As  a  general  rule,  extraction  of  foreign  bodies  should 
be  considered  as  an  operation  to  be  performed  in  interior  hos- 
pitals rather  than  in  the  hospitals  at  the  front." 

Emergency  Operation  for  Open  Thorax. — The  term  "open 
thorax"  is  used  to  describe  those  cases  in  which  the  offending 
missile  has  left  a  gaping  wound  in  the  thoracic  wall.  This 
gaping  wound  must  be  closed  in  order  to  overcome  the  resultant 
mechanical  embarrassment  of  respiration  and  the  resultant 
pleural  infection.  As  a  matter  of  fact,  closure  is  to  be  con- 
sidered as  an  emergency  operation.  Thevenot  has  practiced 
this  type  of  closure  109  times,  with  a  mortality  of  24.7  per 
cent  and  a  subsequent  pleural  infection  of  8  per  cent  of  the 
cases.     The  reason  for  this  high  mortality  rate  is  that  (Theve- 


240  ABSTRACTS  OF  WAR  SURGERY 

not)  the  closure  of  the  thoracic  wound  was  regarded  as  the 
essential  thing.  The  fact  should  be  appreciated  that  such  an 
operation  is  in  reality  an  incomplete  one.  Unless  the  lung  it- 
self be  attacked,  hemorrhage  checked,  foreign  bodies  removed, 
and  asepsis  combated,  one  can  hardly  hope  for  other  than  a 
high  mortality  rate. 

Operative  Technic. — The  first  point  of  importance  in  the 
operative  technic  is  appreciation  of  the  fact  that  one  should 
not  fear  the  entrance  of  air  into  the  pleural  cavity  and  total 
pulmonary  collapse.  Methods  of  combating  this  may  be  ra- 
tional, but  they  are  very  inconvenient  to  perform,  and  if  we 
practise  them  we  must  make  up  our  minds  that  it  will  be  im- 
possible to  relieve  injuries  of  the  lung.  It  is  necessary  to  handle 
the  lung,  to  inspect  it,  to  incise  it,  and  to  swing  it  around  on 
its  pedicle.  In  order  to  do  these  various  things,  the  lung  must 
be  in  a  state  of  collapse.  All  of  the  maneuvers  described 
above,  namely,  the  seizing  of  the  lungs  with  forceps,  separa- 
tion of  adhesions,  traction  on  the  pedicle,  if  they  are  made  with 
gentleness,  have  no  influence  on  the  respiration  of  the  heart. 
The  respiration  maintains  its  normal  rhythm,  frequency,  and 
amplitude.  If,  on  the  other  hand,  we  operate  under  positive 
or  negative  pressure,  the  lung  does  not  collapse,  and  it  can 
not  therefore  be  handled. 

The  heart  is  not  in  the  least  excited,  and  Duval  has  never 
observed  any  reflex  disturbance  of  cardiac  rhythm.  Thoracoto- 
my, with  manipulation  of  the  lung,  is  not  a  shocking  operation. 
Indeed,  even  those  cases  that  come  to  the  field  hospital  in  a 
state  of  moderate  shock  should  not  be  held  until  the  blood  pres- 
sure completely  reestablishes  itself,  but  one  should  rather  be 
inclined  to  hasten  operative  intervention  in  order  to  complete 
it  before  the  lung  enters  the  stage  of  inflammation  which  it 
ordinarily  does  so  quickly  after  injury. 

The  question  of  anesthesia  has  not  been  definitely  settled. 
General  anesthesia  is,  of  course,  treacherous  in  these  cases,  and 
local  anesthesia  in  a  measure  inadequate,  but  when  local 
anesthesia  can  be  used  it  is  the  method  of  choice. 

The  chest  may  be  opened  by  one  of  two  procedures,  either 
by  making  a  thoracic  window  or  by  the  extensive  resection  of 
one  rib.  Duval  has  always  contented  himself  with  a  simple  re- 
section of  10  cm.  of  one  rib,  followed  by  forcible  retraction 
of  the  neighboring  ribs  above  and  below.  In  operations  per- 
formed for  the  late  removal  of  foreign  bodies,  the  chest  should 
be  opened  at  the  point  nearest  to  the  foreign  body,  but  the 


ABSTRACTS  OF  WAR  SURGERY  241 

early  emergency  operations  call  for  extensive  incision  so  as  to 
permit  a  thorough  inspection  of  the  entire  lung.  One  should 
plan  this  incision  rather  with  this  object  in  view  than  with 
any  preconceived  notion  regarding  drainage  of  pleural  cavity. 
It  is  almost  beyond  question  that  the  anteroexternal  incision 
running  from  the  axillary  to  the  parasternal  line  in  the  neigh- 
borhood of  the  fifth  rib  gives  the  best  exposure  of  the  whole 
lung.  It  goes  without  saying,  of  course,  that  special  lesions, 
such  as  rib  fracture,  call  for  special  treatment  and  may  even 
demand  a  second  incision. 

The  French  refer  to  the  delivery  of  the  lung  as  exterioriza- 
tion. When  the  rib  has  been  resected,  the  imprisoned  air  of 
the  pneumothorax  rushes  out  in  gusts.  It  is  well  to  pay  no 
attention  to  this  and  not  to  attempt  to  extract  all  the  air,  but 
to  proceed  at  once  to  treat  the  lung  wound,  leaving  the  re- 
moval of  intrapleural  air  and  blood  for  a  later  stage  of  the 
operation.  The  lung  is  gently  seized  with  light,  elastic,  non- 
crushing fenestral  forceps  and  by  gently  swinging,  rotating 
movements,  the  lobe  is  exteriorized.  It  is  received  immediately 
in  warm,  moist  compresses,  and  is  thereupon  carefully  inspected 
on  all  its  surfaces.  After  the  lesion  is  located,  the  thorax 
opening  is  plugged  by  a  thick  gauze  compress  in  order  to 
obviate  the  to-and-fro  movements  of  air  during  operation.  The 
wound  is  then  dealt  with  appropriately  in  accordance  with  the 
methods  already  described,  and  the  other  lobes  treated  in  turn, 
provided  they  have  been  injured. 

It  is  necessary  to  operate  as  gently  and  quickly  as  possible 
and  to  get  the  opening  in  the  chest  wall  closed  at.  the  earliest 
possible  moment.  In  case  there  should  be  any  evidence  of 
mechanical  interference  with  breathing,  it  is  advisable  rapid- 
ly to  deliver  the  lung,  plugging  the  chest  wall  with  gauze. 
This  procedure  is  usually  followed  by  cessation  of  all  respira- 
tory embarrassment. 

In  case  the  lung  is  bound  down  by  adhesions,  these  are  divided 
gently   and  bluntly  if  possible,   by  sharp   division  if  necessary. 

In  combating  hemorrhage,  three  methods  may  be  used:  Tam- 
ponade, suture,  or  ligature. 

Tamponade  is  not  to  be  advised  except  in  cases  where  the 
wound  is  inaccessible  on  account  of  old  adhesions  or  where  the 
wound  is  large  and  the  infiltrated  lung  tissue  so  friable  as  not 
to  hold  suture  or  ligature. 

Ligature  requires  no  explanation.  It  is  the  ideal  method  of 
hemostasis. 


242  ABSTRACTS  OF  WAR  SURGERY 

Suture,  however,  should  be  explained,  as  it  is  in  a  large  num- 
ber of  cases  effectual  even  when  it  is  used  merely  to  close  the 
opening  of  a  blind  wound  or  openings  of  a  through-and-through 
wound.  According  to  Duval,  this  method  seems  to  be  illogical, 
but  it  has  worked  excellently  in  his  hands. 

The  presence  of  foreign  bodies  in  the  lung  requires  special 
mention.  Radioscopic  examination  furnishes  evidence  regard- 
ing the  presence  of  metallic  foreign  bodies,  but  unfortunately 
does  not  disclose  the  presence  of  bits  of  clothing,  or  even  of 
fairly  good-sized  bits  of  fragmented  bone. 

The  infiltrated  hemorrhagic  lung  does  not  permit  one  to  pal- 
pate, with  any  degree  of  certainty,  bits  of  clothing,  moderate- 
sized  bone  fragments,  and  often  not  even  bullets. 

Metallic  foreign  bodies  may  have  to  be  removed  under  some 
circumstances  with  the  aid  and  under  the  control  of  the  radio- 
scopic screen.  The  foreign  body  is  grasped  by  forceps  in- 
serted in  the  lung  wound  or  through  a  deliberately  made  new 
incision  in  the  lung  substance.  The  wound  should  always  be 
gently  cleansed  with  a  strip  of  gauze,  in  order  to  remove  pos- 
sible foreign  bodies  other  than  those  disclosed  by  x-ray  ex- 
amination, or  recovered  by  the  use  of  forceps. 

After  the  foreign  bodies  have  been  removed  and  the  necrotic 
lung  tissue  cleaned  away  by  the  gauze  strip,  or  when  possible 
after  a  clean  incision  of  the  wound  has  been  made,  the  lung 
wound  is  sutured.  Care  must  be  taken  to  include  the  depths 
of  the  wound  in  the  suture,  and  also  accurately  to  approxi- 
mate the  pleural  edges.  These  sutures  should  not  have  too 
wide  a  bight,  in  order  to  guard  against  their  tearing  through 
lung  substance  during  inspiration,  when  tension  is  put  on 
them. 

After  the  lung  has  been  carefully  attended  to,  the  pleura 
and  pleural  cavity  demand  attention.  The  lung  is  replaced  in 
the  pleural  cavity,  and  gentle  attempts  are  made  with  gauze 
sponges  to  mop  out  every  vestige  of  intrapleural  blood  and 
blood  clot.  It  is,  of  course,  impossible  to  remove  all  the  intra- 
pleural air  as  long  as  the  chest  is  open.  Since  it  is  desirable, 
however,  for  the  sake  of  the  patient's  comfort  to  get  all  this 
air  out,  Duval  recommends  that  it  be  aspirated  with  a  syringe 
after  the  chest  wound  has  been  completely  closed.  This  clos- 
ure of  the  chest  wall  must  be  done  very  carefully  in  order  to 
avoid  the  leakage  of  air;  the  resected  rib  ends  should  be  cov- 
ered with  muscle  in  order  to  get  an  air-tight  wound.  It  goes 
without  saying  that  the  wound  in  the  chest  wall  demands  the 


ABSTRACTS  OF  WAR  SURGERY  243 

usual  careful  operative  treatment  accorded  all  other  war 
wounds. 

As  a  general  proposition,  Duval  is  an  unqualified  advocate 
of  the  practice  of  wound  excision  (when  practicable)  for  the 
lung  and  always  for  the  chest  wall.  Piery  takes  diametrically 
the  opposite  stand,  however,  and  says  that  one  should  not 
practice  excision  of  the  wound.  Gasquet  and  Le  Nouene  agree 
with  this  advice.  Of  course,  this  is  contrary  to  the  usual 
method  of  handling  wounds,  but  except  in  very  rare  cases,  such 
as  subcutaneous  hematomas,  which  harbor  infection,  abscess 
of  the  pleura  requiring  opening,  or  for  late  pneumothorax,  ex- 
cision of  the  wound  is  dangerous. 

The  opening,  caused  by  a  foreign  body  passing  between  the 
ribs,  permitting  the  wound  to  close  itself  behind  it  immediately, 
if  excised,  thereby  creates  a  portal  of  entry  for  infection  of  the 
pleural  cavity.  (De  Martell  makes  this  same  statement  in  re- 
gard to  penetrating  wounds  of  the  skull,  in  which  the  points 
of  entry  and  exit  are  closed.) 

One  must  bear  in  mind  that  although  the  operation  is  de- 
scribed as  sometimes  remarkably  simple,  it  is  nevertheless  ex- 
ceptional for  these  patients  to  run  other  than  a  rather  stormy 
postoperative  course.  Pulmonary  congestion  is  particularly 
frequent,  and  if  it  occurs  on  the  opposite  side  also,  it  is  almost 
always  fatal.  Pain,  restlessness,  and  groaning  are  practically 
constant  postoperative  occurrences.  The  respirations  are  rather 
shallow,  the  pulse  small  and  rapid,  and  the  expectoration 
bloody,  for  the  first  day.  It  is  necessary  that  these  patients 
should  be  kept  in  a  semiupright  posture  and  be  judicially  mor- 
phinized.  The  temperature,  which  is  elevated  after  operation, 
usually  returns  to  normal  about  the  fourth  or  fifth  day,  and 
if  any  air  is  left  in  the  chest  it  is  usually  entirely  absorbed  at 
the  end  of  the  fifth  or  sixth  day.  Sometimes,  the  pleural  reac- 
tion is  manifested  by  a  chill,  followed  by  serofibrinous  or 
hemorrhagic  pleurisy,  which  is  spontaneously  restored. 

From  all  of  this  it  goes  without  saying  that  postoperative 
care  constitutes  a  most  important  chapter.  These  patients 
must  be  made  comfortable,  and  it  is  much  more  difficult  to  do 
this  in  war  hospitals  than  it  is  in  times  of  peace.  They  should 
be  placed  in  a  special  ward  where  the  temperature  is  constant 
and  kept  constantly  above  the  usual  normal  level  and  where 
there  are  no  currents  of  air.  This  ward  should  be  near  the 
operating  room  or  at  all  events  connected  with  it  by  an  in- 
closed, warm  passageway.     These  patients  should  furthermore 


244  ABSTRACTS  OF  WAR  SURGERY 

be  kept  well  protected  by  warm  coverings  and  should  not  be 
permitted  to  breathe  dry,  cold  air.  It  is  advisable  that  im- 
mediately after  operation  they  should  be  placed  in  specially 
warmed  beds, 

GUNSHOT  WOUNDS  OF  THE  LUNGS,  AND  TUBERCULOSIS. 

— H.  Rieder.    Miinchen.  med.  Wchnschr.,  1915,  lxii,  p.  1673. 

The  prognosis  of  gunshot  wounds  of  the  lungs  is  comparatively 
good  so  far  as  immediate  recovery  is  concerned,  but  there  is  no 
doubt  that  they  leave  the  lung  with  a  decreased  functional 
capacity  that  tends  to  favor  the  development  of  tuberculosis  later. 
There  is  no  proof  that  there  is  such  a  thing  as  true  traumatic 
tuberculosis.  But  existing  cases  of  tuberculosis  grow  worse  and  a 
latent  process,  which  perhaps  the  patient  never  knew  of,  may  be 
awakened  into  activity  by  trauma.  Roentgen  examination  often 
shows  the  presence  of  such  an  old  tuberculosis  in  cases  where  it 
had  not  been  clinically  evident. 

The  prognosis  in  posttraumatic  tuberculosis  is  always  grave. 
In  order  to  prevent  it  patients  after  gunshot  wounds  of  the 
lungs  should  be  given  a  period  of  heliotherapy  or  sanitarium 
treatment.  They  should  be  protected  as  far  as  possible  from  con- 
tact with  infection,  should  be  given  respiratory  gymnastics  for 
several  weeks  after  the  injury,  and  for  several  months  periodical 
examinations  should  be  made  of  the  lungs,  even  when  there  are 
no  symptoms. 


CARDIOVASCULAR  SURGERY. 

INJURY  OF  THE  HEART  BY  THE  BURSTING  OF  A  GREN- 
ADE; EXTRACTION  OF  PROJECTILE  FROM  THE 
RIGHT  VENTRICLE;  RECOVERY.— Beaussanat.  Bull,  de 
I' Acad,  de  med.,  Paris,  1915,  lxxiii,  p.  554. 

Beaussanat  describes  a  case  of  operation  for  injury  of  the 
heart  which  illustrates  the  remarkable  tolerance  of  this  organ.  A 
sergeant  was  struck  by  a  bursting  grenade.  A  fragment 
was  removed,  and  he  was  then  discharged,  but  for  four 
months  continued  to  have  difficulty  in  breathing  and  precordial 
distress,  worse  at  night  and  when  lying  down.  He  had  to  move 
gently  and  speak  slowly  to  avoid  making  his  symptoms  worse. 
After  roentgen  examination  a  diagnosis  was  made  of  a  fragment 
of  shell  in  the  pericardium.  On  incising  the  pericardium,  how- 
ever, the  fragment  could  not  be  seen,  but  it  could  be  felt  free  in 
the  right  ventricle.  The  heart  was  brought  outside  the  peri- 
cardium and  held  by  two  silk  threads  passed  through  the  muscle. 
The  fragment  was  brought  as  near  to  the  apex  of  the  ventricle  as 
possible  and  held  by  the  thumb  behind  and  three  fingers  in  front 
while  an  incision  was  made  through  which  it  was  extracted.  It 
weighed  1.5  gms.  The  heart  was  sutured  with  silk.  For  three 
days  the  patient  had  intense  dyspnea,  the  pulse  was  feeble  and 
irregular  and  the  facies  anxious.  There  were  three  attacks  of 
cough  and  blood-stained  sputum,  evidently  from  pulmonary  em- 
bolism. But  in  a  month  the  patient  had  completely  recovered 
and  auscultation  showed  the  heart  normal. 

CONSERVATIVE  OR  OPERATIVE  TREATMENT  OF  HEART 
WOUNDS. — A.  Schafer.  Munchen.  med.  Wchnschr.,  1915, 
lxii,  p.  647. 

Schafer  describes  two  cases  in  which  he  sutured  the  heart ;  one 
a  case  of  stab  wound  with  suicidal  intent,  the  other  an  accidental 
gunshot  injury.  Both  cases  recovered.  He  concludes  that  opera- 
tion is  not  only  justified  but  unconditionally  indicated  in  gunshot 
injuries  of  the  heart  if  they  can  be  operated  upon  within  a  few 
hours  after  the  injury  with  proper  aseptic  precautions. 

245 


246  ABSTRACTS  OF  WAR  SURGERY 

Ether  is  the  best  anesthetic ;  stimulants  are  contraindicated  be- 
fore the  operation,  as  they  increase  the  bleeding ;  after  the  opera- 
tion they  are  of  value  combined  with  the  administration  of  physio- 
logical salt  solution.  The  intercostal  incision  is  the  best.  Positive 
or  negative  pressure  apparatus  is  not  necessary;  in  most  cases 
pneumothorax  has  already  occurred  from  the  wound  and  even 
if  produced  by  the  operation  it  is  not  of  great  consequence.  The 
author  thinks  drainage  of  the  pericardium  is  dangerous  and 
drainage  of  the  pleura  unnecessary.  Fixation  of  the  lung  to  the 
anterior  ribs  hastens  the  reexpansion  of  the  lung. 

VASCULAR  INJURIES  IN  WAR.— Rev.  of  War  Surg,  and  Med., 
September,  1918,  i,  No.  7. 

Anatomical  Considerations. — Inasmuch  as  the  course  of  vas- 
cular lesions  is  determined  by  the  general  characteristics  of  the 
wound,  which,  in  turn,  depends  upon  the  types  of  projectiles  em- 
ployed, Sencert  (Blessures  des  Vaisseaux,  Masson  et  Cie,  English 
translation,  Appleton  &  Co.)  points  out  the  anatomical  possibilities 
involved. 

Isolated  injury  of  either  artery  or  vein  may  occur,  but  associated 
wounds  of  both  artery  and  vein  are  more  frequent.  Any  of  the 
types  of  injuries  given  below  may  involve  vein  or  artery  alone  or 
both  simultaneously.  Any  of  these  varieties  of  wounds  may  be 
found  in  combination. 

It  is  particularly  important  to  note  that  not  only  may  the  artery 
and  its  companion  vein  be  injured,  but  the  Avound  may  involve  also 
collateral  branches  arising  below  the  point  of  injury  and  situated 
on  a  deeper  plane  or  a  bifurcating  branch  behind  the  chief  trunk. 
This  multiplicity  of  lesions  is  important  from  the  point  of  view  of 
treatment,  forming  one  of  the  chief  reasons  for  the  preference  given 
by  some  surgeons  to  the  method  of  ligation  in  the  wound  itself 
over  that  of  tying  the  vessels  above  the  injury.  Reference  to  this 
point  is  made  under  treatment. 

Types  of  Vascular  Wounds. — The  types  of  wounds  of  vessels 
seen  in  the  present  war  vary  with  the  types  of  projectiles  em- 
ployed, and  as  the  range  of  weapons  used  is  greater  than  in  any 
previous  war,  so  the  wounds  seen  exceed  in  variety  and  severity 
those  which  have  characterized  previous  warfare. 

Thus,  as  Seucert  points  out,  vascular  wounds  produced  by  rifle 
bullets,  shrapnel  balls,  shell  fragments,  grenades,  and  aerial  torpe- 
does vary  greatly  one  from  another.    Wounds  caused  by  rifle  bullets 


ABSTRACTS  OP  WAR  SURGERY  247 

may  be  lateral  and  partial,  complete  and  circumferential,  or  per- 
forating. Grenade  fragments  may  cause  actual  punctures,  more  or 
less  extensive  lateral  tears,  amounting  sometimes  to  complete  rup- 
ture, true  perforation,  which  is  a  rare  lesion,  and  complete  division 
or  crushing,  as  when  limbs  are  torn  off  or  severely  crushed  by  large 
fragments  of  shell  or  by  minor  projectiles.  In  cases  of  the  last- 
mentioned  type  the  artery  or  vein  may  be  seen  gaping,  or  lacerated 
and  flattened,  but  not  bleeding,  on  the  surface  of  the  stump  or  at  the 
bottom  of  the  extensive  wound. 

In  lateral  wounds  which  are  caused  by  projectiles  striking  the 
outer  third  or  fourth  of  the  transverse  diameter  of  the  vessel,  the 
adventitia,  the  middle  coat  and  the  internal  coat,  are  lacerated, 
while  radiating  rents  of  the  intima,  of  varying  extent,  prolong  the 
external  lacerations  along  the  interior  of  the  vessel.  The  wound  is 
enlarged  and  hemorrhage  is  favored,  in  consequence  of  the  retracti- 
bility  of  the  middle  coat,  which  tends  to  separate  the  lips  of  the 
wound  and  to  cause  a  slight  change  in  the  axis  of  the  vessel,  so  that 
the  segments  above  and  below  are  deflected  toward  each  other. 

Lateral  wounds  vary  in  size  from  a  mere  slit  to  complete  division 
of  the  vessel. 

In  medium-sized  arteries  complete  division  is  almost  the  only  kind 
of  wound  encountered,  and  it  is  more  frequent  than  one  would  sup- 
pose even  in  large  vessels.  The  explanation  offered  for  the  frequency 
of  this  type  of  wounds  in  large  arteries  is  the  fact  that  at  short 
range  the  explosive  effect  of  the  bullet  is  such  that  the  artery  tra- 
versing its  track  is  extensively  torn  and  broken  up,  sometimes  with 
great  loss  of  substance.  At  medium  or  long  range,  on  the  other 
hand,  the  bullet  is  less  stable,  and  consequently  is  very  easily  di- 
verted, so  that  the  arterial  wall  is  hit  more  or  less  obliquely  by  the 
side  instead  of  the  point  of  the  bullet.  The  vessel  is  thus  torn  as 
by  a  large  projectile. 

For  the  reasons  just  given,  few  perforations  are  met  with  in 
arteries,  and  then  only  in  the  larger  trunks.  The  perforations  are 
smaller  when  the  velocity  of  the  bullet  is  low.  There  may  be  a 
perforation  of  artery  and  vein,  complete  division  of  both  vessels, 
or  a  lateral  wound  of  each. 

In  bullet  wounds,  as  a  rule,  if  the  range  is  fairly  long,  the  orifices 
of  entrance  and  of  exit  are  punctiform,  and  the  whole  track,  subcu- 
taneous, aponeurotic,  and  muscular,  is  barely  visible  on  operation. 
The  tissues,  separated  for  a  moment,  close  up  in  normal  position  and 
resume  their  normal  relationships  directly  the  bullet  has  passed. 
No  foreign  body  is  left  in  the  track,  inasmuch  as  the  bullet  pene- 


248  ABSTRACTS  OF  WAR  SURGERY 

trates  the  clothing  by  severing  the  threads,  pushing  no  debris  before 
it.    Such  wounds,  therefore,  are  not  septic. 

Shell  wounds,  on  the  other  hand,  are  broad  and  narrow,  never 
punctiform.  The  cutaneous  opening  is  irregular,  with  contused  and 
lacerated  edges  exuding  a  sanguineous  fluid.  Beneath  the  skin  the 
cellular  tissue  is  lacerated,  the  aponeurosis,  torn  or  perforated, 
covers  a  deep  and  tortuous  cavity  in  which  the  muscle  lies  contused 
and  crushed.  Contusion  and  sepsis  are  the  leading  characteristics  of 
such  wounds.  The  degree  of  the  contusion  may  be  such  that  actual 
mortification  of  the  tissue  results.  The  extent  of  the  contusion 
caused  by  shell  wounds  is  always  greater  than  the  apparent  limits 
of  the  wound,  and  includes,  to  a  varying  depth,  the  whole  length 
of  the  track,  whether  subcutaneous,  muscular,  or  osseous. 

Pathological  Considerations. — The  pathological  course,  as  well 
as  the  anatomical  characteristics,  of  bullet  wounds  differ  from  that 
of  shell  wounds. 

In  vascular  bullet  wounds  three  conditions  are  encountered  which 
are  of  particular  interest  in  vascular  surgery:  (1)  Spontaneous 
hemostasis  from  cicatricial  closure,  more  or  less  complete;  (2) 
diffuse  hematoma;  (3)  traumatic  aneurisms. 

Spontaneous  Hemostasis  (so-called  Dry  Wounds). — An  arterial 
bullet  wound  is  immediately  followed  by  an  escape  of  blood  which 
is  effused  round  the  vessel.  The  perivascular  sheath,  supported  and 
kept  rigid  by  the  neighboring  tissues,  is  not  destroyed  by  the  bullet 
in  its  passage.  A  few  muscular  fibers  are  separated,  but  these  come 
together  again  after  the  bullet  has  passed.  There  is  no  bullet  track, 
and  no  wound  cavity.  The  escaping  blood,  therefore,  immediately 
encounters  this  perivascular  barrier,  and  is  thus  prevented  from 
spreading  very  far.  Confined  in  this  manner,  the  blood  coagulates 
rapidly  in  the  immediate  neighborhood  of  the  vessel,  forming  a 
clot  which  closes  the  arterial  wound  like  a  plug  or  cork.  This  spon- 
taneous hemostasis  is  favored  by  the  anatomical  conditions  in  com- 
plete division  of  the  artery,  the  retraction  and  curling  up  of  the 
middle  and  internal  coats  within  the  adventitia  obliterating  the 
lumen  of  the  artery.  In  a  lateral  wound,  on  the  contrary,  there  is 
retraction  of  the  internal  coat  only,  which  tends  to  render  the  wound 
more  gaping. 

Once  this  preliminary  hemostasis  is  established,  cicatrization  of 
the  vascular  wound  proceeds  rapidly,  and  may  involve  both  ends  of 
the  divided  vessel. 

Sencert  (Lyon  chir.,  1917,  xiv,  640,  abstracted  in  Surg.,  Gyn. 
and  Obst.,  January,  1918),  reported  20  cases  of  injuries  to  the 


ABSTRACTS  OF  WAR  SURGERY  249 

axillary,  femoral,  and  popliteal  vessels,  arriving  at  the  ambulance, 
in  which  there  was  already  spontaneous  hemostasis. 

Alamartine  {Lyon  chir.,  1917,  xiv,  687,  abstracted  in  Surg.,  Gyn. 
and  Obst.,  February,  1918),  reported  32  cases  of  so-called  dry  vas- 
cular injuries.  The  clinical  types,  he  holds,  are  conformable  to  the 
anatomic  types,  and  are  divisible  into  three  groups:  (a)  Those 
showing  symptoms  or  arteriovenous  fistulae;  (b)  arterial  wounds  or 
arteriovenous  wounds  with  diffuse  hematoma;  (c)  traumatic  aneur- 
isms. The  32  cases  observed  included  5  of  arteriovenous  fistulae ;  21 
of  arterial  or  arteriovenous  wounds  with  diffuse  hematoma;  6  of 
traumatic  aneurism. 

Perrenot  {Rev.  de  chir.,  Par.,  1917,  liii,  232,  abstracted  in  Surg., 
Gyn.  and  Obst.,  March,  1918)  records  four  cases  of  so-called  "dry" 
vascular  wounds,  all  found  at  operation:  (1)  Wounds  of  the  two 
humeral  veins  with  contusion  of  the  artery;  (2)  an  arteriovenous 
fistula  of  the  femoral  vessels  in  Scarpa's  triangle;  (3)  a  lateral 
wound  of  the  humeral  artery;  (4)  complete  rupture  of  the  humeral 
artery.  In  all  these  cases  hemorrhage  from  the  injured  vessels  was 
prevented  by  clot  formation  which  was  sufficiently  strong  to  prevent 
the  flow. 

In  seeking  the  cause  of  this  phenomenon  of  "dry"  vascular 
wounds,  Perrenot  finds  that  they  occur  when  the  agent  is  a  piece  of 
shell  and  not  a  bullet.  In  this,  it  will  be  noted,  his  observation  is 
diametrically  opposed  to  that  of  Sencert,  who  points  out  the  reasons 
bullet  wounds  may  be  characterized  by  spontaneous  hemostasis 
(dry  wounds). 

A  bullet,  according  to  Perrenot,  makes  a  clean  section  in  the  ves- 
sel, with  considerable  hemorrhage  and  the  rapid  development  of 
hematoma,  whereas  shell  injuries  are  contused  and  lacerated 
wounds.  The  projectile  is  usually  found  in  an  "attrition  chamber" 
of  lacerated  tissue  which  forms  its  walls;  and  when  the  projectile 
is  large,  these  walls  may  be  several  millimeters  thick.  An  important 
vessel  may  become  incorporated  in  such  a  chamber.  Even  if  com- 
pletely sectioned,  its  walls  may  be  pressed  against  each  other  by 
one  of  the  projectile  surfaces.  The  area  all  around  is  contused  and 
every  condition  for  the  formation  of  a  clot  is  present. 

There  is  another  type  of  spontaneous  hemostasis,  to  be  referred 
to  later,  in  which,  although  the  wound  is  dry,  the  spontaneous 
closure  of  the  vessel  is  so  insecure  that  dangerous  secondary  hemor- 
rhage is  of  frequent  occurrence. 

Diffuse  Hematoma. — Spontaneous  hemostasis  and  cicatricial  clos- 
ing pf  the  wound  resulting  in  the  so-called  dry  wound,  form  the  ex- 


250  ABSTRACTS  OF  WAR  SURGERY 

ceptional  rather  than  the  usual  course  of  an  arterial  bullet  wound, 
according  to  Sencert.  Under  the  influence,  he  says,  of  the  repeated 
pulsations,  the  blood  extravasated  outside  the  vessel  tends  gradually 
to  infiltrate  beyond  the  sheath  into  the  intercellular  spaces  and  the 
interstices  of  neighboring  muscles.  Once  the  cellular  tissue  has 
given  way,  the  infiltration  continues  until  the  pressure  of  the  ex- 
travasated fluid  equals  the  arterial  tension.  Owing  to  the  fact  that 
the  wounds  in  the  different  tissue  layers  do  not  correspond,  the 
blood  does  not  reach  the  cutaneous  wound  and  can  not  escape  ex- 
ternally. Thus  a  diffuse  arterial  hematoma  is  formed.  The  hema-, 
toma  is  superficial,  forming  a  tumor  visible  to  the  eye,  when  the 
vessel  is  subcutaneous  or  superficial,  as  the  femoral  in  Scarpa's  tri- 
angle or  the  brachial  at  the  bend  of  the  elbow.  On  the  other  hand, 
if  the  vessel  is  deep,  like  the  popliteal  or  the  posterior  tibial,  the 
hematoma  is  infiltrated  into  the  interstices  of  the  deep  muscles,  dis- 
tending and  swelling  the  limb,  but  not  forming  a  visible  tumor.  By 
following  the  adventitia  of  the  collateral  vessels,  it  may  pass  from 
one  muscular  layer  to  another.  A  diffuse  hematoma  of  the  super- 
ficial femoral,  for  example,  may  extend  into  the  region  of  the  ad- 
ductors, and  thence,  by  following  the  course  of  the  perforating  ar- 
teries, it  may  reach  the  posterior  aspect  of  the  thigh.  The  hema- 
toma may  be  multilocular  in  character,  presenting  an  anterior  and 
a  posterior  sac  separated  by  a  muscular  wall.  When  the  deep  and 
superficial  femoral  are  both  wounded  at  the  same  time,  a  multi- 
locular hematoma  is  apt  to  form. 

This  periarterial  effusion  of  blood  is  variously  termed  diffuse 
aneurism,  false  aneurism,  diffuse  aneurismal  hematoma,  or  pulsating 
hematoma.  Sencert  considers  these  terms  are  meaningless,  and 
agrees  with  Monod  that  arterial  hematoma,  the  name  originally  ap- 
plied by  Cruveilhier,  sufficiently  describes  the  condition. 

The  blood,  coming  in  contact  with  the  limiting  tissues,  gradually 
coagulates  at  the  periphery  of  the  effusion.  The  coagulated  blood 
contracts,  the  irregular  prolongations  of  the  effusion  are  reduced, 
and  the  hematoma,  as  it  becomes  established,  assumes  a  certain 
regularity.  There  follows  infiltration  of  serum  and  leucocytes  into 
the  neighboring  tissues  which  have  been  irritated  by  the  clot,  and 
a  sort  of  edematous  perihematie  mass  is  formed ;  this  later  becomes 
a  firm  lardaceous  wall,  gradually  differentiated,  by  progressive  tis- 
sue organization,  in  proportion  to  the  age  of  the  hematoma.  Coin- 
cidentally,  the  deposition  of  clots  assumes  the  form  of  white  lamina- 
tion, which  lines  the  internal  surface  of  the  sac,  giving  it  the  ap- 
pearance of  a  vessel  wall.    This  phenomenon  accounts  for  the  fact 


ABSTRACTS  OF  WAR  SURGERY 


251 


that  a  hematoma  is  sometimes  mistaken  for  a  true  aneurism.  The 
pseudo-sac  of  this  encysted  arterial  hematoma  may  be  made  to  dis- 
appear, up  to  at  least  the  fifth  week,  by  pressing  out  the  contained 
clots.  There  is,  therefore,  no  true  aneurismal  wall  which  may  be 
isolated  and  removed. 

The  less  fortunate  course  of  an  encysted  arterial  hematoma  may 
involve  its  progressive  growth  and  its  infection,  to  which  reference 
is  made  under  treatment.  Its  more  favorable  course  involves  its 
metamorphosis  into  a  true  arterial  aneurism. 

Aneurism  (arterial,  arteriovenous,  aneurismal  varix). — The  de- 
velopment of  an  arterial  hematoma  into  a  true  arterial  aneurism 
takes  place,  according  to  Sencert,  in  the  following  manner:  The 
inflammatory  connective  tissue  wall  becomes  defined  and  hardened, 
and  the  peripheral  layers  of  the  clot  become  laminated  and  adherent 
to  it.  The  center  of  the  hematoma,  on  the  other  hand,  which  is  close 
to  the  arterial  wound,  and  is  continuously  under  the  influence  of 
the  systolic  pulsations,  becomes  softened,  and  is  gradually  hollowed 
out  into  a  regularly  shaped  cavity,  into  which  the  bloodstream  en- 
ters with  each  heartbeat.  The  pressure  of  the  circulating  blood 
against  the  wall  of  this  cavity  causes  it  to  become  thinner,  and  it  is 
more  or  less  completely  lined  by  an  endothelial  proliferation  from 
the  edges  of  the  arterial  opening.  A  sac  with  organized  walls,  lined 
with  endothelium  and  bounded  by  a  progressively  defined  connective 
tissue  sac,  is  thus  formed  round  the  vessel.  It  is  in  direct  communi- 
cation with  the  interior  of  the  artery,  and  pulsates  synchronously 
with  it.  The  types  of  arteriovenous  aneurism  are  illustrated  in 
Figs.  1  to  5. 


TYPES    OP   ARTERIOVENOUS   ANEURISM 

1.  Direct   communication  between   artery   and  vein. 

2.  Vein  evenly  dilated. 

3.  Venous  sac. 

4.  Connecting  fibrous  canal. 

5.  Intermediate  sac. 

When  an  arterial  bullet  wound  is  associated  with  a  wound  of  the 
accompanying  vein,  the  following  circumstances  may  ensue: 
(1)   The  bullet  may  pass  between  the  artery  and  the  vein,  in- 


252  ABSTRACTS  OF  WAR  SURGERY 

flicting  a  lateral  wound  on  each.  The  two  orifices  may  correspond 
exactly,  and,  from  the  beginning,  may  adhere  so  accurately  and  so 
completely  by  their  margins  that  there  is  no  appreciable  effusion 
of  blood  around  the  vessels.  These  cases  are  not  frequent.  "Where 
the  two  openings  do  not  exactly  correspond,  conditions  are  favor- 
able for  the  formation  of  an  arteriovenous  hematoma,  but  the  ex- 
travasated  blood  so  easily  finds  the  central  end  of  the  vein,  and  is 
so  rapidly  taken  up  by  it,  that  nothing  remains  but  a  slight  effusion 
in  the  perivascular  sheath. 

Cicatrization  of  the  two  wounds  is  accomplished  by  an  endothelial 
proliferation,  which  quickly  unites  the  edges  of  the  fistula.  Be- 
tween the  two  vessels,  above  and  below  the  opening,  the  blood  takes 
part  in  the  organization  of  a  fibrous  tissue  connection  between  the 
arterial  and  venous  walls  for  a  distance  of  an  inch  or  more. 

This  adhesion  of  the  two  vessels  is  of  great  importance,  since 
it  prevents  the  ligation  of  the  communication  and  the  reconstruction 
of  the  two  vessels  by  a  double  suture. 

Dilatation  of  the  central  and  peripheral  ends  of  the  vein  in  the 
neighborhood  of  the  union  is  an  invariable  and  immediate  conse- 
quence of  arteriovenous  communication.  The  venous  tension  is 
enormously  increased  in  consequence  of  the  violent  projection  of 
blood  toward  both  ends  of  the  vein,  which  dilates  and  thickens, 
presenting  the  characteristic  features  of  aneurismal  varix.  The 
dilatation  may  be  regular,  and  spindle-shaped,  as  in  I  of  diagram. 
It  may  become  irregular  and  bulging,  forming  an  arteriovenous 
aneurism,  with  the  sac  entirely  venous,  as  in  II  of  diagram,  or  the 
central  end  of  the  artery  may  become  thin  and  atrophied,  losing 
its  tension,  and  becoming  dilated,  thus  forming  the  simplest  type  of 
arteriovenous  aneurism. 

(2)  The  bullet  may  cause  a  double  perforation  of  artery  and 
vein ;  it  may  make  a  lateral  wound  in  the  artery,  with  complete  di- 
vision of  the  vein,  or  vice  versa;  it  may  completely  divide  both 
artery  and  vein.  Immediately  after  the  passage  of  the  bullet,  in 
every  case,  there  is  hemorrhage,  arterial  and  venous,  which  spreads 
around  the  vessels,  inside  and  outside  of  the  adventitia,  like  a  diffuse 
arterial  hematoma.  This  diffuse  hematoma  is  soon  bounded  by  an 
inflammatory  wall,  being  thus  transformed  into  an  encysted  hema- 
toma, the  center  of  which  is  a  channel  of  communication  between 
the  artery  and  the  vein.  This  intermediate  hematoma  may  undergo 
progressive  retraction  until  a  small  fibrous  canal,  about  half  an  inch 
in  length,  unites  the  two  vessels,  as  shown  in  III  of  the  diagram. 
In  other  cases  the  vessels  are  united  by  a  true  sac,  as  in  IV  of  dia- 


ABSTRACTS  OF  WAR  SURGERY  253 

gram.  The  communication  may  take  place  in  the  vicinity  of  a  trib- 
utary vein.  The  arteriovenous  aneurism,  in  such  cases,  assumes 
forms  and  relationships  difficult  to  anticipate,  and  it  occurs  in  all 
possible  varieties,  from  the  simplest  to  the  most  complex  varicose 
aneurism. 

Wounds  from  shell  splinters  are  divided  by  Sencert  into  two 
classes:  (1)  Those  in  which  the  external  wound  gapes  widely;  (2) 
those  in  which  it  is  partially  or  completely  obliterated. 

Of  the  first  category  are  the  extensive,  widely  gaping  wounds 
made  by  large  splinters  and  the  still  more  widely  gaping  wounds 
due  to  comminuted  fractures  with  much  cutaneous  and  muscular 
laceration,  or  to  the  loss  of  the  whole  limb.  Hemorrhage,  primary, 
reactionary,  or  secondary,  one  or  all,  are  the  concomitants  of 
wounds  of  this  character,  in  which  crushing  and  contusion  play  an 
important  part. 

Various  factors  tend  to  check  the  dangerous  and  often  fatal  pri- 
mary hemorrhage.  Those  of  secondary  importance  are  diminution 
of  arterial  tension  due  to  acute  anemia,  retardation  of  the  blood 
flow,  and  syncope.  Of  primary  importance  is  the  high  degree  of 
contusion  of  the  vessel  in  the  neighborhood  of  the  actual  wound. 
In  lesions  of  this  kind,  with  no  sign  of  hemorrhage,  careful  ex- 
amination will  reveal  that  the  middle  and  internal  coats  of  the  vessel 
are  mangled  and  frayed,  with  hanging  shreds  which  adhere  to- 
gether, favoring  the  obliteration  of  the  vessel.  The  protecting  clot 
thus  formed  often  extends  an  inch  above  the  wound. 

This  spontaneous  hemostasis,  quite  unlike  that  of  the  so-called 
dry  wounds  already  described,  is  extremely  precarious,  since  the 
slightest  movement,  sometimes  a  mere  increase  in  the  blood  pressure, 
may  displace  the  clot,  even  after  hours,  and  set  up  a  fresh  reaction- 
ary and  perhaps  fatal  hemorrhage. 

In  the  majority  of  cases  (9  times  out  of  10,  according  to  Sencert) 
the  large  vessel  lying  injured  at  the  bottom  of  this  gaping  shell 
wound  is  discovered  and  complications  averted  by  suitable  treat- 
ment. Sometimes,  however,  the  case  may  be  regarded  as  one  of 
simple  injury  of  the  soft  parts.  Such  wounds,  open,  gaping,  and 
exposed  to  air  and  light,  however  contused  and  septic,  will  never 
become  the  seat  of  serious  and  rapid  sepsis.  It  can  never,  as  in  the 
case  of  the  narrow,  confined  wound,  become  a  closed  chamber  for 
the  multiplication  of  germs,  and  it  is  exceptional  that  gangrene  and 
diffuse  suppuration  are  found  in  it,  a  simple  localized  infection  dur- 
ing the  progressive  elimination  of  the  contused  walls  of  the  injured 
area  being  the  usual  course. 


254  ABSTRACTS  OF  WAR  SURGERY 

It  is  not  unusual,  however,  for  the  vascular  wall,  severely  bruised 
for  some  distance  from  the  wound,  to  undergo  gradual  necrosis,  in 
which  event  the  separation  of  the  resulting  slough,  8,  10,  or  12  days 
after  injury,  may  open  the  vessel  above  the  obliterating  clot.  The 
inevitable  secondary  hemorrhage  may  prove  fatal  at  once,  or  it 
may  recur  until  death  is  the  final  outcome. 

This  type  of  wounds  without  hemorrhage  apparently  called  forth 
the  recent  observations  of  Neuberger  (Rev.  gen.  de  clin.  de  therap., 
1917,  xxxi,  16,  251),  who  reports  a  series  of  cases  seen  in  a  surgical 
ambulance  of  which  he  was  director,  which  were  interesting  by  vir- 
tue of  the  fact  that  the  wounds  were  dry  for  a  period  of  eight  hours 
after  injury,  and  then  the  vascular  injury  became  known  as  the  re- 
sult of  severe  hemorrhage.  The  significance  of  these  wounds,  Neu- 
berger warns,  is  that  they  indicate  the  necessity  of  immediate  in- 
vestigation of  all  wounds  that  lead  to  the  suspicion  of  vascular 
injury,  even  though  there  be  no  active  hemorrhage.  Unfortunately, 
the  absence  of  pulse  does  not  help  one  in  reaching  a  conclusion  re- 
garding the  presence  of  these  dry  wounds,  because  the  vessel  is 
not  infrequently  thrombosed  as  a  result  merely  of  vascular  con- 
tusion. Neuberger  quite  graphically  characterizes  these  wounds 
as  "mute"  wounds,  on  account  of  the  scarcity  of  symptoms,  and 
says  one's  chief  reliance  in  making  a  diagnosis  is  the  fact  that  an- 
atomically the  course  of  the  projectile  is  such  that  probably  a  large 
vessel  is  injured.  The  reason  for  these  dry  wounds  is  that  the 
internal  tunic  curls  out  in  the  lumen  of  the  vessel,  forming,  with 
the  tissue  debris  and  coagulum,  a  progressively  formed  closure. 

In  the  second  class  of  shell  wounds,  viz.,  punctured  wounds,  or 
those  in  which  the  external  wound  is  partially  or  completely  closed, 
the  conditions  are  quite  different  from  those  enumerated  in  connec- 
tion with  gaping  wounds.  There  is  not  the  external  hemorrhage  of 
external  wounds,  but  instead,  a  diffuse  arterial  hematoma,  some- 
times of  enormous  size,  is  formed,  as  with  the  bullet  wounds  previ- 
ously described.  The  contusion  of  the  vessel  and  the  extensive 
laceration  of  the  internal  coat  for  some  distance  from  the  wound 
greatly  facilitate  arterial  thrombosis  and  spontaneous  hemostasis. 
The  effusion  may  be  sufficiently  extensive  to  reach  collateral 
branches,  obstructing  them  and  thus  facilitating  the  rapid  gangrene 
of  the  wounded  limb.  Wounds  of  this  type,  moreover,  unlike  the 
extensive  gaping  wounds,  are  severely  septic  from  the  beginning, 
the  infection  often  being  accompanied  by  the  evolution  of  gas.  The 
increased  distension  caused  by  the  gas  completes  the  blocking  of 
the  collateral  vessels,  rendering  gangrene  inevitable.     Instead  of 


ABSTRACTS  OF  WAR  SURGERY  255 

an  anaerobic  infection  leading  to  gas  gangrene  or  gaseous  cellu- 
litis, a  simple  slow  phlegmonous  inflammation,  leading  to  simple 
suppuration  of  the  hematoma,  may  develop.  This  state  of  affairs 
is  particularly  apt  to  involve  small  hematoma.  Secondary  hemor- 
rhage is  the  natural  termination.  Thus,  when  shell  wounds  are 
narrow  and  restricted,  septic  arterial  hematoma  results.  If  this 
is  considerable,  it  leads  to  septic  gangrene ;  if  small,  to  local  sepsis 
and  secondary  hemorrhage. 

Contusion  of  vessels. — Contusion,  which  plays  so  important  a  role 
in  the  subsequent  history  of  extensive  shell  wounds  involving  large 
blood  vessels,  may,  under  certain  exceptional  circumstances,  ac- 
company bullet  wounds,  but  vascular  contusion  is  more  frequently 
caused  by  shell,  grenade,  or  torpedo  than  by  bullet. 

A  spent  ball,  or  a  ball  which  has  been  retarded  by  passing 
through  a  bone,  may  be  arrested  in  contact  with  a  large  vessel,  which 
is  struck  more  or  less  violently  but  is  not  ruptured.  Contusion  may 
be  caused  by  the  passage  of  a  ball  at  some  distance  from  the  vessel. 

The  mechanism  of  contusion  varies.  It  may  be  the  outcome  of 
direct  shock,  as  where  an  artery  is  struck  by  a  spent  ball.  Direct 
shock  is  more  frequent  in  association  with  wounds  caused  by  shrap- 
nel balls  than  by  bullets  of  small  caliber.  Contusion  may  result 
from  hydraulic  shock  to  the  vessel,  effected  at  the  moment  when  the 
ball  comes  in  contact  with  it  or  with  the  tissues  in  its  immediate 
neighborhood.  It  is  more  frequently  due,  however,  to  the  elongation 
or  stretching  of  the  vessel. 

In  contusion  caused  by  fragments  of  shell,  grenade,  or  torpedo 
the  mechanism  may  involve  direct  shock,  indirect  shock  conveyed 
from  a  distance,  or  the  overstretching  of  the  vessel.  The  degree  of 
contusion  varies  from  immediate  and  rapid  gangrene  at  the  site  of 
injury  to  slight  bruising  at  a  distance.  The  degree  of  contusion 
varies  with  the  volume  and  velocity  of  the  projectile,  on  the  one 
hand,  and  its  distance  from  the  direct  point  of  contact,  on  the  other. 

Experimental  observations  have  led  to  the  differentiation  of  three 
degrees  of  contusion,  involving,  respectively,  the  internal  coat  only, 
in  the  first ;  both  the  middle  and  internal  coats,  in  the  second ;  and 
rupture  of  the  intima  and  media  circularly  around  the  entire  cir- 
cumference of  the  vessel,  in  the  third.  These  experimental  findings 
have  been  confirmed  by  the  surgical  experience  of  the  war. 

Contusion  of  the  first  or  second  degree,  when  it  is  the  sole  injury, 
is  too  slight  a  lesion  to  produce  appreciable  symptoms.  In  cases 
characterized  by  contusion  of  the  so-called  secondary  degree,  in 
which  thrombosis  occurs,  secondary  symptoms  resulting  from  the 


256  ABSTRACTS  OF  WAR  SURGERY 

migration  of  clots  from  the  thrombosed  portion  of  the  vessel  give 
the  only  evidence  of  the  contusion.  If  the  embolus  is  arrested  in 
the  cerebral  vessels,  hemiplegia  or  monoplegia,  transitory  or  per- 
sistent, results ;  if  in  the  peripheral  arterioles  of  the  limbs,  cutane- 
ous sloughs,  or  even  dry  gangrene  result.  Such  lesions  are  signifi- 
cant in  connection  with  vascular  suture,  to  which  reference  is  made 
later. 

Contusion  of  the  third  degree  sometimes  appears  as  a  narrow 
constriction  corresponding  to  the  site  of  retraction  of  the  torn  inner 
coats.  As  a  rule,  however,  a  fusiform  dilatation  of  the  vessel  is 
seen,  on  exposure,  corresponding  to  the  contused  portion,  the  wall 
of  which  is  formed  only  by  the  adventitia. 

Effect  of  Contusion  on  Contents  of  Vessel. — In  contusion  of  the 
first  degree  the  characteristic  fine  striation  of  the  intima  does  not, 
as  a  rule  affect  the  circulation  of  the  blood  through  the  vessel.  In 
contusion  of  the  second  degree  thrombus  formation  is  a  frequent 
accompaniment,  the  thrombosis  varying  from  the  lateral  thrombus 
very  limited  in  extent,  to  the  thrombus  that  completely  occludes 
the  lumen  of  the  vessel. 

In  contusion  of  the  third  degree — subadventitial  rupture  of  the 
internal  coats — thrombosis  is  the  invariable  accompaniment.  Pri- 
mary thrombosis,  the  direct  outcome  of  the  laceration  of  the  internal 
coats,  may  be  complicated  by  secondary  thrombosis  due  to  infection 
of  the  wound  in  the  neighborhood  of  the  contused  vessel. 

Involvement  of  the  Periarterial  Sympathetic. — Burrows  (Brit. 
Med.  Jour.,  Feb.  16,  1918,  199)  calls  attention  to  the  fact  that  in 
war  injuries  of  main  blood  vessels,  little  inquiry  has  been  made 
into  the  effects  upon  structures  which  lie  within  the  area  of  dis- 
tribution. Injury  of  a  main  artery—such,  for  example,  as  the 
common  femoral,  the  popliteal,  or  the  brachial — may  produce  im- 
mediate and  remarkable  consequences  in  the  affected  limb.  Inas- 
much as  the  ensuing  symptoms  are  paralytic,  they  are  apt  to  be 
regarded  either  as  "functional"  or  as  arising  from  concomitant 
nerve  lesions.  Owing  to  the  close  association  and  common  ana- 
tomical relations  between  the  vessels  and  the  nerves,  simultaneous 
injuries  of  the  structures  are  indeed  of  frequent  occurrence.  Eleven 
cases  are  detailed  by  Burrows  to  show  the  extensive  paralytic  phe- 
nomena that  may  follow  a  vascular  lesion  independently  of  any 
nerves. 

The  main  symptoms  are:  (1)  Subjective  sensation  in  the  distal 
part  of  the  affected  limb;  (2)  anesthesia,  more  or  less  of  the 
"stocking"  or  "glove"  type,  and  involving  all  kinds  of  sensation, 


ABSTRACTS  OF  WAR  SURGERY  257 

including  light  touch,  pin-pricks,  and  deep  pressure;  (3)  muscular 
paralysis;  (4)  in  certain  cases  hardness  and  inelasticity  of  the 
muscles;   (5)  edema. 

It  is  noted  that  in  all  cases  in  which  no  arterial  pulse  could  be 
felt  distally  to  the  injury  the  patients  complained  of  subjective 
sensations,  variously  described  by  them,  but  referred  to  by  the 
writer  as  "pins  and  needles."  On  the  other  hand,  in  cases  in  which 
a  distal  pulse  could  be  felt  there  were  no  "pins  and  needles."  In 
these  cases  the  area  of  anesthesia  was  most  extensive,  reaching  to  a 
level  considerably  above  the  wound.  Cutaneous  sensibility  was  lost 
in  all  cases  tested  except  one.  Motor  paralysis  was  present  in  all. 
In  one  case  muscular  and  sensory  paralysis  rapidly  passed  away 
after  a  wounded  popliteal  artery  had  been  ligated  together  with 
the  vein.  When  the  distal  pulse  was  not  obliterated,  with  motor 
and  sensory  paralysis,  the  muscles  were  flaccid  and  soft;  whereas, 
in  cases  of  complete  arterial  lesion,  the  muscles  were  hard.  No 
case  of  paralysis  was  observed  as  a  sequence  of  injury  to  the  radial. 
The  pressure  of  packing  may  have  played  a  subsidiary  part  in  the 
causation  of  symptoms  in  cases  in  which  the  wounds  were  plugged 
at  the  time  of  admission  to  the  general  hospital. 

The  fact  that  ligature  of  an  artery  in  one  patient  may  lead  to 
little  or  no  evil  consequences,  while  in  another,  seemingly  as  favor- 
able at  the  time  of  operation,  grave  consequences  may  follow,  is 
difficult  to  explain.  In  one  case  cited  fracture  close  to  above  the 
elbow- joint,  ligature  of  the  brachial  artery  seemed  to  exercise  a 
favorable  influence.  Cases  of  this  sort  illustrate  the  fact  that  what- 
ever the  actual  cause  of  angiotic  paralysis  may  be  it  is  not  clearly 
defined  at  present. 

The  following  theory  concerning  the  pathology  of  the  cases  under 
consideration  is  given  by  Burrows : 

The  attractive  and  simple  course  of  attributing  all  the  nerve 
phenomena  to  ischemia — to  an  insufficient  supply  of  blood  to  the 
tissues — at  once  suggests  itself,  and,  if  we  follow  this  course,  we  may 
describe  the  symptoms  collectively  under  the  title  of  ischemic 
paralysis,  and  be  done  with  all  further  speculation.  Objections, 
however,  to  this  title  become  apparent  on  close  scrutiny.  In  the 
first  place,  it  involves  the  acceptance  of  a  hypothesis  of  causation 
which  at  present  is  not  fully  established.  The  symptoms  may  be 
due  to  the  small  quantity  of  blood  which  is  circulating,  to  injury  of 
the  sympathetic  nerves  in  the  vessel  sheath,  to  the  low  pressure  of 
the  blood  stream  below  the  injured  artery,  to  cold,  to  some  other 
cause  altogether,  or  to  a  combination  of  causes.    Moreover,  although 


258  ABSTRACTS  OP  WAR  SURGERY 

some  of  the  cases  just  described  show  that  a  paralysis  similar  to  the 
so-called  Volkmann's  ischemic  paralysis  often  does  follow  occlusion 
of  an  artery,  yet  it  is  clear  that  this  is  not  the  only  form  of  paralysis 
which  may  follow  a  vascular  lesion. 

For  these  reasons  it  appears  better  to  adopt  a  general  title  which 
will  not  implicate  us  in  any  hypothesis  other  than  that  the  symp- 
toms are  consequent  upon  damage  to  a  blood  vessel.  Accordingly, 
the  term  "angiotic  paralysis"  may  be  applied  with  convenience  to 
the  symptoms  described  in  these  cases. 

At  the  outset  we  must  assume  that  two  factors  at  least  take  part 
in  the  causation  of  the  symptoms.  On  the  other  hand,  we  may  have 
extensive  degeneration  of  muscle  and  massive  gangrene,  without 
any  loss  of  cutaneous  sensibility,  except  in  the  area  of  mortification, 
while  on  the  other  there  may  be  widespread  loss  of  sensation  and 
muscular  power  without  gangrene,  without  gross  myopathic  change, 
and  even  without  obliteration  of  the  distal  pulse.  From  this  it  is 
clear  that  there  is  no  exact  correlation  between  the  neuropathic  and 
the  myopathic  symptoms. 

Probably  ischemia  is  one  of  the  factors,  the  one  which  is  asso- 
ciated especially  with  Volkmann's  myopathy.  If,  however,  we 
accept  ischemia  as  the  cause  of  this  myopathy,  there  must  be  at 
least  some  other  cause  for  the  flaccid  paralysis  and  sensory  loss 
which  are  to  be  observed  after  certain  vascular  injuries  in  which  the 
artery  is  not  completely  divided  or  obstructed,  and  in  which  the 
distal  pulse  can  still  be  felt.  The  fundamental  cause  in  these  cases 
seems  to  be  the  actual  damage  to  the  arterial  wall  or  to  its  sheath, 
rather  than  any  consequent  effect  upon  the  supply  of  blood  to  the 
limb.  Further,  it  appears  that  an  incomplete  injury — that  is  to 
say,  an  injury  in  which  the  artery  is  not  completely  severed — is 
more  likely  to  be  followed  by  extensive  sensory  loss  and  flaccid 
paralysis  than  is  a  complete  division  or  ligation  of  the  artery. 
There  is  reason  to  suppose  that  these  symptoms  are  reflex  in  nature. 
Accepting  this  to  be  so,  we  classify  the  effects  of  arterial  injuries 
into  ischemic  paralysis  and  reflex  paralysis. 

Let  us  consider  these  two  factors  in  detail.  A  wound  in  the 
popliteal  region  is  followed  by  absence  of  pulsation  in  the  dorsalis 
pedis  and  posterior  tibial  arteries.  The  foot  becomes  cold  and 
white,  and  remains  so  for  24  hours,  at  the  end  of  which  time  there 
are  signs  of  returning  circulation,  except  in  the  toes  and  a  small 
portion  of  the  foot,  which  become  gangrenous.  The  whole  leg  up 
to  the  knee  is  slightly  edematous;  the  muscles  are  hard  and  abso- 
lutely  paralyzed.      Inspection    of   the   muscles   after   amputation 


ABSTRACTS  OF  WAR  SURGERY  259 

show  them  to  have  undergone  a  striking  change  of  color— they  are 
no  longer  red,  but  quite  pale  and  almost  buff-colored.  This  change 
affects  some  of  the  muscles  more  than  others,  and  the  change  is 
more  complete  in  the  distal  than  in  the  proximal  ends  of  the 
muscles.  What  the  actual  change  and  its  cause  may  be  we  do  not 
know,  though  the  suggestion  has  been  made  that  it  is  identical 
with  rigor  mortis.  Sections  of  the  muscles  in  this  case  were  made, 
and  the  following  pathological  report  rendered: 

"Portions  of  the  peronei  and  gastrocnemius  muscles  were  cut; 
each  showed  gross  pathological  changes.  No  normal  muscle  fibers 
were  seen.  In  sections  stained  by  hemalum  and  eosin  the  general 
impression  was  that  given  by  an  anemic  infarct.  The  muscle  fibers 
and  the  interstitial  tissues  stained  a  uniform  pink.  The  fibers 
showed  various  stages  of  degeneration — some  had  almost  normal 
striation  but  no  nuclei ;  others  had  completely  lost  their  striation, 
and  appeared  as  granular  masses.  Fibers  showing  different  degrees 
of  change  were  often  found  next  to  each  other.  The  majority  of 
fibers  appeared  swollen.  Some  were  broken  up  into  irregular 
masses;  others  were  split  into  longitudinal  fibrillae  and  transverse 
discs.  There  was  no  hyaline  degeneration,  and  no  gross  fatty 
change  was  seen.  The  interstitial  tissue  appeared  edematous, 
stained  a  faint  pink  with  Van  Gieson,  and  was  almost  cell-less. 
There  were  few  capillaries.  Throughout  the  sections  there  was  but 
little  trace  of  inflammatory  reaction.  The  large  vessels,  arteries, 
and  veins  contained  blood,  not  clot,  and  appeared  normal. ' ' 

The  characteristics  of  ischemic  cases  are  summarized  as  follows : 

1.  An  arterial  injury  with  obliteration  of  the  distal  pulse. 

2.  Subjective  sensation  of  "pins  and  needles." 

3.  Muscular  paralysis;  the  muscles  being  hard  and  inelastic  to 
the  touch. 

4.  Anesthesia  of  a  "stocking"  or  "glove"  distribution,  confined 
to  the  portion  of  limb  which  is  distal  to  the  injury,  and  involving 
all  forms  of  sensation. 

Seven  of  the  writer's  cases  belonged  to  the  ischemic  type  of 
paralysis  (Volkmann's  ischemic  paralysis).  The  damaged  muscles 
do  not  recover.  Any  resumption  of  function  is  attributable  to  the 
fact  that  portions  of  the  muscles,  especially  the  proximal  portions, 
usually  escape  and  are  capable  of  limited  activity  later  on. 

The  cases  in  which  the  paralysis  has  seemed  to  be  of  a  reflex 
nature  have  the  following  characteristics : 


260  ABSTRACTS  OF  WAR  SURGERY 

1.  An  arterial  injury  without  complete  blockage  of  the  vessel. 

2.  Absence  of  "pins  and  needles"  sensation. 

3.  Flaccid  paralysis  of  the  muscles  which  do  not  feel  hard  and 
inelastic. 

4.  Widespread  loss  of  cutaneous  sensibility,  extending  in  two 
instances  well  above  the  level  of  the  wound. 

These  cases,  according  to  Burrows,  give  the  impression  of  being 
less  organic  than  the  ischemic  ones.  The  hypothesis  that  these  cases 
are  of  a  reflex  nature  has  been  adopted  partly  for  convenience  of 
argument,  but  largely  because  this  explanation  seems  plausible. 
The  suggestion  that  the  anesthesia  is  of  a  functional  nature  was 
not  borne  out  by  several  controls — patients  with  fractures,  wounded 
joints,  and  other  bad  wounds  of  limbs,  in  whom  tests  revealed  no 
case  of  "stocking"  anesthesia  except  in  those  who  had  arterial 
lesions. 

In  his  general  conclusions  the  writer  sounds  a  warning  note  in 
giving  the  following  advice : 

"Although  the  importance  of  these  paralytic  effects  of  arterial 
injuries  can  not  at  present  be  estimated,  yet,  until  we  are  better 
informed  as  to  prognosis,  we  may  well  be  more  reluctant  in  the 
future  than  we  have  been  in  the  past  to  tie  a  main  artery  for  the  ar- 
rest of  hemorrhage. 

' '  We  shall  be  more  particular  and  persistent  in  our  endeavors  to 
find  the  exact  source  of  bleeding,  in  the  hope  that  it  may  prove  to 
concern  a  branch  only  instead  of  the  main  trunk.  And,  in  those 
instances  in  which  the  main  trunk  itself  is  wounded,  we  shall  be 
more  disposed  to  cure  the  leak  by  suture  of  the  vessel,  or  failing 
this,  to  attempt  an  escape  from  the  ill  consequences  of  direct  liga- 
ture by  the  temporary  use  of  the  Tuffier  tube.  Furthermore,  when 
we  are  compelled  by  the  nature  of  the  case  to  tie  a  main  artery,  we 
shall  take  care  to  tie  the  main  vein  also;  because,  as  Sir  George 
Makins  has  pointed  out,  the  results  which  follow  ligation  of  both 
vessels  are  better  than  those  which  ensue  upon  a  blockage  of  the 
main  artery  alone. ' ' 

Leriche  and  Heitz  {Lyon  chir.,  1917,  xiv,  754,  abstracted  in  Surg., 
Gyn.  and  Obstet.)  give  very  complete  clinical  histories  of  18  cases 
of  reflex  nerve  disturbances  consecutive  to  war  wounds  which  they 
treated  by  periarterial  sympathectomy.  They  have  attempted  to 
show  what  may  be  demanded  and  expected  from  sympathectomy  in 
the  treatment  of  contractures  and  paralysis  of  the  Babinski-Fro- 
ment  type. 

The  operation  is  performed  by  a  thorough   dissection   of  the 


ABSTRACTS  OF  WAR  SURGERY  261 

cellular  arterial  sheath  carrying  the  sympathetic  vasomotor  fibers, 
or,  if  the  artery  is  occluded,  the  whole  thrombosed  segment  is  re- 
sected. 

The  results  of  the  operations  carried  out  demonstrate  several 
facts : 

1.  The  operation  is  followed,  after  a  short  period  of  arterial  con- 
striction during  the  manipulations  of  the  vessel,  by  an  elevation  of 
the  blood  pressure  in  the  operated  limb. 

2.  Operation  is  always  followed,  after  the  period  of  arterial  con- 
striction, by  an  intensive  vasodilatation,  lasting  for  several  weeks 
and  resulting  in  a  considerable  elevation  of  the  temperature  of  the 
subjacent  segment  of  limb. 

3.  The  resection  of  an  obliterated  artery  produces  the  same  re- 
action of  vasodilatation,  but  even  more  intensive  and  lasting  than 
sympathectomy  by  denudation. 

4.  Both  operations  have  a  striking  action  on  the  voluntary  con- 
traction of  the  muscles  whose  motor  power  was  abolished  before. 

Circulatory  disturbances  in  paralysis  and  reflex-contractures  are 
constantly  accompanied  by  local  vasoconstriction  which  may  tem- 
porarily disappear  by  artificial  heating.  Hence  the  favorable  action 
of  periarterial  sympathectomy  is  satisfactorily  explained  by  the 
vasodilatation  and  consecutively  increased  temperature  produced; 
and  concerning  muscular  contracture,  by  the  intensified  blood  irri- 
gation of  the  muscles  which  bring  more  oxygen  and  stimulate  the 
process  of  dissimilation. 

The  disappearance  of  reflex  disturbances,  contractures,  numbness, 
cyanosis,  edema,  etc.,  is  not  always  definite  at  once,  and  it  may  be 
advisable  to  aid  the  effects  of  vasodilatation  obtained  by  sympa- 
thectomy by  hot  baths  of  paraffin  and  by  suitable  exercises.  But  in 
any  case  the  resultant  improvement,  even  in  the  most  severe  cases, 
is  sufficient  to  justify  the  intervention. 

Although  sympathectomy  is  not  proposed  for  cases  in  which  the 
vasomotor  and  thermic  disturbances  are  not  pronounced,  the  inter- 
vention is  inoffensive.  In  no  case  where  the  operation  was  done  was 
the  patient's  condition  aggravated,  and  in  most  cases  the  authors 
have  observed  a  period  of  change  which  tended  toward  recovery. 

Leriche  (Bull,  et  mem.  de  la  Soc.  de  Chir.  de  Par.,  1917,  xliii, 
No.  5,  310)  calls  attention  to  the  train  of  symptoms  ordinarily 
characterized  as  trophic  consequent  upon  arterial  ligature  or  injury. 
This  syndrome  as  seen  in  the  upper  extremity  may  be  described  as 
presenting  the  following  symptoms :  The  hand  is  cold,  bluish,  the 
skin  glossy,  the  fingers  numb  and  stiff,  the  muscles  of  the  forearm 


262  ABSTRACTS  OF  WAR  SURGERY 

hard,  rigid,  and  atrophic.    In  addition  to  this  there  is  no  pulse  and 
the  arterial  pressure  is  either  zero  or  very  feeble. 

This  symptom  complex  is  very  paradoxical  in  that  it  has  the 
appearance  of  being  venous  stasis,  and  yet  there  is  no  rational  basis 
for  assuming  such  a  stasis  to  exist.  According  to  Leriche,  the 
explanation  lies  rather  in  the  fact  that  the  sympathetic  nervous 
mechanism  has  in  some  way  been  injured.  Leriche  characterizes 
the  lesion  as  "lesion  du  sympathique  periarterielle,"  and  advises 
that  in  all  instances  of  arterial  ligature  the  vascular  sheath  be 
divided.  In  other  words,  that  what  he  calls  a  peripheral  sympa- 
thectomy be  done.  He  cites  cases  to  show  that  this  procedure  is 
followed  by  an  immediate  disappearance  of  all  trophic  symptoms, 
and  although  admitting  that  he  can  not  furnish  an  absolutely  re- 
liable explanation,  he  tentatively  explains  the  improvement  by  the 
fact  that  the  injury  to  the  vessel  has  set  up  some  sort  of  disturbed 
nervous  impulse  in  the  sympathetic  leading  to  vasoconstriction,  and 
that  the  sympathectomy,  causing  the  immediate  vasodilatation, 
brings  with  it  marked  improvement  of  symptoms.  Leriche  is  frank 
to  say  that  observations  are  not  yet  sufficiently  numerous  to  permit 
one  to  say  that  the  relief  is  permanent.  As  a  matter  of  fact,  one 
may  expect  in  10  days  or  2  weeks,  in  a  certain  percentage  of 
cases,  a  return  of  the  vasomotor  syndrome. 

Since  Leriche  published  his  first  results  from  denudation  and 
excision  of  the  sympathetic  periarterial  plexus  in  neuralgia  and 
other  trophic  disturbances  others  have  tried  the  operation.  He  now 
reports  37  cases  upon  which  he  has  personally  operated.  (Presse 
med.,  Paris,  1917,  p.  513,  abstracted  in  Surg.,  Gyn.  &  Obst.,  March, 
1918.) 

The  operation  should  be  more  precisely  termed  a  peripheric  sym- 
pathectomy, and,  according  to  the  situation,  should  be  designated 
as  axillary,  humeral,  femoral,  etc. 

When  the  artery  is  laid  bare  the  cellular  sheath  is  opened  by  the 
bistoury,  the  artery  is  isolated  for  8  or  10  centimeters,  and  as  far  as 
possible  is  denuded  of  all  adhering  tissues,  either  with  the  bistoury 
or  a  cannulated  sound.  By  careful  manipulation  the  arterial  wall 
is  not  menaced  while  the  cellular  decortication  is  being  done.  The 
wound  is  then  closed  by  layers. 

Arterial  sympathectomy  is  followed  by  a  characteristic  physio- 
logic reaction.  From  the  very  first  intervention  on  the  sympathetic 
sheath  there  is  contraction  of  the  artery.  The  caliber  is  reduced  to 
one-third  or  one-fourth  the  normal  size  over  the  whole  denuded 
segment.     The  segments  immediately  above  and  below  keep  their 


ABSTRACTS   OF    WAR   SURGERY  263 

normal  volume.  The  rapidity  with  which  this  occurs  varies  in 
different  patients,  and  the  contraction  is  more  marked  in  arteries  of 
medium  caliber  than  in  the  larger  trunk  vessels. 

The  secondary  signs  are  a  weakening  or  imperceptibility  of  the 
pulse  and  numbness  in  the  limb,  observed  in  the  first  hours  after 
operation;  but  in  from  3  to  15  hours  the  characteristic  reaction 
occurs.  It  is  marked  by  a  local  increase  in  temperature  of  from  2° 
to  4°  and  by  elevation  of  arterial  pressure.  The  reactions  are  tem- 
porary and  last  for  about  15  days. 

A  study  of  the  first  operative  results  shows : 

1.  That  voluntary  muscular  contraction  apparently  depends  on 
the  sympathetic. 

2.  The  method  of  production  of  "dry"  arterial  wounds,  which 
are  at  least  facilitated  by  the  arterial  contraction  occurring  after 
destruction  of  the  sympathetic,  is  explainable. 

3.  The  true  nature  of  certain  neuralgias,  if  not  of  all,  as  such  are 
cured  by  excision  of  the  periarterial  sympathetic  nerves. 

4.  The  sympathetic  nerves  play  an  important  part  in  the  produc- 
tion of  Babinski-Froment  reflexes,  and  also  of  the  motor  paralyses 
which  follow  certain  arterial  lesions. 

The  author  has  performed  sympathectomy  in  different  types  of 
cases — in  those  in  which  the  chief  element  was  pain,  in  those  with 
contracture,  or  with  vasomotor  or  trophic  disturbances.  In  11  cases 
the  operation  was  done  for  pain ;  some  patients  were  entirely  cured, 
but  it  does  not  give  an  absolute  result,  although  often  favorable. 
Five  cases  were  operated  upon  for  trophic  ulcerations  and  all  were 
successful.  Three  cases  were  for  large  edemata;  one  resulted  suc- 
cessfully, one  relieved  the  symptoms,  and  one  gave  an  incomplete 
result.  In  18  cases  operated  upon  for  reflex  disturbances  there  were 
3  practically  complete  recoveries,  10  showing  more  or  less  improve- 
ment, 2  showing  improvement  followed  by  recurrence,  1  in  which 
after  a  check  voluntary  movements  were  resumed,  and  2  complete 
failures. 

In  the  severe  forms  of  the  Babinski-Froment  syndrome  hot  paraf- 
fin baths,  with  massage  and  reeducation,  were  found  necessary  to 
supplement  the  operation  in  order  to  obtain  the  best  results. 

Therapeutic  Considerations. — In  extensive  wounds,  with  or 
without  loss  of  a  portion  of  a  limb,  profuse  external  hemorrhage, 
primary  or  reactionary,  and  the  resulting  acute  anemia  (shock) 
are  the  immediate  indications  for  intervention. 

Hemorrhage. — In  the  trenches,  according  to  Sencert,  on  the 
field,  and  even  at  the  aid  post  temporary  arrest  of  hemorrhage  is 


264  ABSTRACTS  OF  WAR  SURGERY 

all  that  is  possible.  The  best  method  of  accomplishing  this  is  by- 
compressing  the  limb  above  the  wound.  The  elastic  bandage  found 
in  the  stretcher-bearer 's  bag,  a  napkin,  a  handkerchief,  the  wounded 
man 's  necktie,  or  a  boot  lace  are  usually  employed  for  this  purpose, 
a  piece  of  wood,  a  stone,  or  a  lump  of  turf  being  slipped  between 
the  band  and  the  skin  to  convert  the  former  into  a  tourniquet.  It 
is  important  to  bear  in  mind,  however,  that  a  tourniquet  should 
not  be  applied  unless  it  is  fairly  certain  that  a  large  artery  is 
wounded.  Not  only  orderlies  and  stretcher-bearers,  but  medical 
officers  as  well,  too  often  apply  the  tourniquet  indiscriminately, 
thus  gravely  endangering  both  life  and  limb.  If  the  constriction 
is  soon  removed,  the  danger  is  insignificant,  but  prolonged  con- 
striction is  conducive  to  gangrene  of  the  portion  of  the  limb  thus 
isolated.  The  propagation  of  germs  deposited  on  the  surface  of 
the  wound  is  favored  by  the  devitalized  and  anemic  condition  of  the 
tissues,  and  under  these  circumstances  the  development  of  gas 
gangrene  is  favored.  A  special  label  should  be  attached  when,  a 
tourniquet  has  been  applied,  as  indication  that  the  case  is  suitable 
for  evacuation. 

In  wounds  so  located  that  a  tourniquet  can  not  be  employed,  as 
at  the  root  of  a  limb,  in  Scarpa's  triangle,  the  axilla  or  the  neck, 
temporary  arrest  of  hemorrhage  under  emergency  conditions  may  be 
effected  (1)  by  direct  pressure  upon  the  bleeding  point,  exerted  by 
means  of  one  or  more  fingers  thrust  into  the  wound  or  by  an  extem- 
porized pressure  pad,  and  (2)  by  temporary  closure  of  the  skin 
wound,  as  by  means  of  Kocher's  forceps. 

When  hemorrhage  has  been  controlled  by  such  temporary  meas- 
ures as  are  feasible,  the  patient  is  conveyed  to  a  dressing  station 
without  loss  of  time.  Here  the  surgeon  endeavors  to  secure  per- 
manent hemostasis  and  to  overcome  the  profound  anemia. 

Permanent  Hemostasis. — When  a  main  vessel  is  wounded,  per- 
manent hemostasis  may  be  accomplished  in  one  of  three  ways  (1)  by 
ligature;  (2)  by  prolonged  f orcipressure ;  (3)  by  vascular  suture. 

Ligature  of  both  ends  of  the  divided  artery  (Sencert  maintains, 
contrary  to  general  opinion,  that  No.  2  catgut  is  strong  enough 
for  the  largest  artery)  brings  about  permanent  hemostasis  by  the 
following  mechanism :  When  the  ligature  is  tied  tightly  the  middle 
and  internal  coats  are  ruptured  and  retract  within  the  adventitia, 
their  extremities  coming  together  in  the  form  of  an  actual  ' '  dome. 
Union  by  first  intention,  or  cicatrization  with  a  minimum  of  throm- 
bus, takes  place,  provided  two  essential  conditions  are  maintained : 
(1)  That  the  ligature  remains  aseptic;  (2)  that  it  is  applied  to  a 


ABSTRACTS  OF  WAR  SURGERY  265 

healthy  portion  of  the  vessel.  Union  by  first  intention  may  be 
interfered  with  by  sepsis  or  vascular  contusion.  However  slight  the 
sepsis  in  the  region  of  the  vascular  wound,  and  however  inconsider- 
able the  lesion  extending  up  the  internal  coat,  the  blood  coagulates 
in  the  end  of  the  vessel,  the  clot  in  the  central  end  projects  for  a 
varying  distance  into  the  lumen,  possibly  blocking  an  important 
collateral  branch. 

The  maintenance  of  the  aseptic  condition  of  the  ligature  presup- 
poses its  use  in  a  surgically  prepared  field.  It  is  easy  to  foresee  the 
difficulties  involved  in  the  ligature  of  an  artery  at  the  bottom  of  a 
war  wound  the  walls  of  which  have  been  contused  and  devitalized 
from  the  beginning,  on  the  surface  and  in  the  depths  of  which 
germs,  carried  in  with  the  projectile,  multiply  rapidly.  The  diffi- 
culties are  further  increased  when,  under  the  influence  of  the  de- 
fensive reactions  of  the  'body,  all  the  dead  skin,  cellular  tissue, 
muscle  and  bone  forming  the  walls  of  the  wound  become  liquefied, 
detached  from  the  surrounding  healthy  tissues,  and  gradually  elim- 
inated. Inflammation,  ranging  in  intensity  from  a  simple  and 
transient  serous  discharge  to  a  profuse  and  persistent  suppuration, 
is  the  natural  consequence. 

Sencert  is  very  emphatic  in  his  belief  that  the  safe  method  of 
preventing  suppuration  in  war  wounds  is  by  the  immediate  excision 
of  the  contused  tissues.  The  cutaneous  edges  of  the  wound,  the 
cellular  tissue,  the  debris  of  muscle  and  aponeuroses  should  all  be 
excised.  Free  and  adherent  splinters  of  bone  should  be  removed, 
leaving  a  large,  clean  wound  with  fresh  bleeding  walls,  at  the  bot- 
tom of  which  lies  the  injured  artery.  The  first  condition  of  success- 
ful arterial  ligation  is  thus  assured. 

The  excision  of  the  contused  and  infected  tissues  makes  possible 
the  fulfilment  of  the  second  condition  of  successful  ligature,  namely, 
the  application  of  the  ligature  to  a  healthy  part  of  the  vessel.  An 
aseptic  ligature  thus  effected  will  progress  under  aseptic  conditions, 
and  terminate  in  cicatrization  of  the  artery  without  thrombosis. 
Former  experience  favorable  to  the  permanent  control  of  hemor- 
rhage by  means  of  ligature  has  been  abundantly  confirmed  by 
results  obtained  in  war  wounds. 

The  method  is  not  devoid  of  danger,  however,  the  abrupt  sup- 
pression of  the  circulation  in  the  area  supplied  by  the  vessel  tend- 
ing to  result  in  gangrene  of  the  limb.  Statistics  published  before 
1914  show  that  the  average  incidence  of  gangrene  was  as  follows : 

After  ligature  of  the  subclavian,  in  5  per  cent  of  cases;  after 
ligature  of  the  axillary,  in  15  per  cent  of  cases;  after  ligature  of 


266  ABSTRACTS  OP  WAR  SURGERY 

the  brachial,  in  5  per  cent  of  cases;  after  ligature  of  the  common 
iliac,  in  50  per  cent  of  cases ;  after  ligature  of  the  common  femoral, 
in  25  per  cent  of  cases;  and  after  ligature  of  the  popliteal,  in  15 
per  cent  of  cases. 

These  figures  are  not  representative  of  recent  vascular  wounds,  as 
they  include  ligature  in  diffuse  arterial  hematoma  and  in  aneurism. 
On  the  other  hand,  gunshot  wounds  are  more  liable  to  gangrene 
than  those  of  any  other  class,  inasmuch  as  they  are  invariably  con- 
tused and  are  associated  with  extensive  laceration  and  contusion  of 
the  neighboring  arteries  and  veins.  The  ischemia  provoked  by  the 
application  of  a  tourniquet,  the  vasomotor  disturbances  due  to  irri- 
tation of  the  collateral  vessels  and  the  contusion  of  the  periarterial 
sympathetic  nerve  plexuses  are  all  factors  that  inevitably  predis- 
pose to  ischemic  gangrene  of  the  limb.  Despite  all  this,  gangrene 
after  ligature  of  a  recently  wounded  artery  is  exceptional.  The 
circulation  after  ligature  is  rapidly  reestablished  by  way  of  the 
collateral  vessels,  and  at  the  end  of  three  or  four  days  the  pulse 
reappears.  In  the  majority  of  cases,  therefore,  simple  ligature 
of  a  large  artery  is  not  in  itself  sufficient  to  provoke  gangrene. 

The  true  causes,  then,  of  gangrene  after  ligature,  are  those  that 
impede  the  establishment  of  the  collateral  circulation,  such  as  vas- 
cular thrombosis,  reaching  from  the  ligature  to  the  collaterals  above ; 
and  periarterial  hematoma,  which  compresses  the  collateral  above 
and  below  the  wound. 

Ligature,  then,  of  a  sound  portion  of  an  arterial  trunk  in  a  large 
wound  which  has  been  surgically  prepared  is  accompanied  by  only 
slight  risk  of  ischemic  gangrene. 

Forcipressure,  which  is  a  makeshift  procedure  to  be  employed 
only  where  ligature  is  impossible,  is  rarely  indicated  in  recent  vas- 
cular injuries,  nor  does  it  altogether  apply  to  old  and  infected 
wounds  and  to  secondary  hemorrhage. 

Suture  of  a  vessel  is  in  theory  the  ideal  method  for  the  perma- 
nent arrest  of  hemorrhage,  since  it  assures  hemostasis,  at  the  same 
time  preserving  the  lumen  of  the  vessel  intact.  Its  success,  how- 
ever, depends  upon  the  same  conditions  as  apply  to  ligature,  viz., 
the  aseptic  course  of  the  suture,  and  the  absence  in  the  neighbor- 
hood of  the  suture  of  lesions  likely  to  provoke  thrombosis.  Owing 
to  the  specific  anatomical  conditions  incidental  to  war  wounds,  ar- 
terial suture  is  in  general  a  long  and  complex  operation,  which  is 
assured  of  success  only  when  preceded  by  extensive  excision  of 
the  wound.  As  Sencert  points  out,  this  explains  why  the  number 
of  arterial  sutures  done  since  the  beginning  of  the  war  is  limited. 


ABSTRACTS  OF  WAR  SURGERY  267 

The  decision  in  favor  of  ligature  is  natural  in  view  of  the  simple, 
easy,  and  certain  method  it  presents,  almost  entirely  free  from 
danger,  contrasted  with  arterial  suture,  a  long  and  tedious  opera- 
tion, leading,  at  great  cost,  to  the  same  results. 

In  Sencert's  opinion,  nevertheless,  suture  should  not  be  excluded. 
If,  when  the  wound  is  well  opened  up,  excised  and  cleansed,  hemor- 
rhage controlled,  and  the  arterial  wound  examined,  extensive  lacera- 
tion is  found,  or  if  there  is  complete  rupture,  with  or  without  loss 
of  substance,  each  end  of  the  artery  should  be  ligatured  in  the 
wound. 

Where  there  is  a  slight  lateral  wound  the  choice  lies  between 
section  of  the  vessel  with  ligature  of  both  ends  and  lateral  suture. 
In  such  a  case  the  edges  of  the  wound  should  be  caught  with  fine 
forceps  and  everted,  the  artery  emptied  by  washing  it  out  with  a 
little  saline  solution,  and  the  damage  then  examined  at  leisure.  If 
the  lesions  are  very  limited  and  there  is  no  laceration  of  the  in- 
tima,  lateral  suture  may  be  safely  undertaken.  When  the  condi- 
tions are  the  reverse  of  these,  the  vessel  should  be  divided  and  each 
end  ligated. 

Sencert  sums  up  the  question  of  ligature  versus  suture  by  the 
statement  that  ligature  is  the  method  par  excellence  for  the  arrest 
of  hemorrhage  from  recent  vascular  wounds  and  that  indications 
for  suture  are  exceptional. 

Acute  anemia,  the  second  indication  for  immediate  intervention 
in  extensive  wounds,  is  overcome  by  the  use,  in  addition  to  minor 
measures  (warmth,  bandaging  the  limbs  over  a  wool  compress, 
inclination  of  the  body  with  the  head  low,  oxygen  inhalation,  hypo- 
dermic injections  of  ether,  camphorated  oil,  or  strychnine),  of 
injections  of  physiological  saline  solution,  direct  transfusion  of 
blood  by  means  of  Elsberg's  cannula,  or  indirect  transfusion  by 
means  of  tubes  sterilized  in  paraffin  (Carrel's  method  modified  by 
Berard). 

Sencert  voices  the  opinion  of  the  majority  of  surgeons  when  he 
states  that  for  everyday  use  the  intravenous  injection  of  physio- 
logical saline  solution  is  the  best  method  because  of  its  simplicity, 
rapidity,  and  efficacy. 

In  punctured  wounds,  including  penetrating  bullet  wounds  with 
punctiform  skin  wounds,  and  penetrating  or  perforating  wounds 
produced  either  by  a  shrapnel  ball  or  a  fragment  of  shell,  grenade, 
or  torpedo,  certain  manifestations  are  to  be  reckoned  with ;  namely, 
(1)  internal  hemorrhage;  (2)  hematoma;  (3)  wounds  without 
hemorrhage. 


268  ABSTRACTS  OF  WAR  SURGERY 

Internal  hemorrhage  occurs  in  association  with  penetrating 
wounds  of  the  chest  and  abdomen.  Inasmuch  as  this  discussion 
does  not  embrace  regional  vascular  surgery,  consideration  of  the 
subject  here  may  be  limited  to  the  following  general  statements : 

(1)  Intraperitoneal  hemorrhage  constitutes  one  of  the  most  im- 
perative indications  for  immediate  laparotomy. 

(2)  Pleural  hemorrhage,  on  the  other  hand,  seldom  calls  for 
exploratory  thoracic  operation  unless  the  vessel  wounded  is  def- 
initely determined. 

When  the  pleural  hemorrhage  is  of  parietal  origin  it  is  amen- 
able to  direct  surgical  hemostasis.  When  it  is  derived  from  the 
root  of  the  lung  it  is  almost  invariably  beyond  the  resources  of 
surgery. 

Hematoma,  the  mechanism  of  production  of  which  is  outlined 
above,  calls  for  therapeutic  measures,  the  aims  of  which  are  largely 
preventive ;  and  directed  against  the  appearance  of  gangrene,  ische- 
mic or  septic,  or  both. 

To  prevent  ischemic  gangrene  in  the  presence  of  extensive  and 
rapidly  forming  hematoma  it  is  necessary  to  evacuate  the  hema- 
toma, the  centrifugal  pressure  of  which  obliterates  the  collateral 
circulation,  and  to  guard  against  its  recurrence  by  permanent  hemo- 
stasis. To  prevent  a  gangrene  which  is  both  ischemic  and  septic, 
the  wound  should  be  freely  opened  and  all  its  ramifications  laid 
bare.  All  clots,  which  are  very  susceptible  to  infection,  all  infective 
portions  of  clothing,  as  well  as  the  missile  itself,  should  be  removed. 
In  other  words,  a  blind  contused  wound  should  be  transformed 
into  an  open  and  clean  one. 

Preventive  hemostasis  should  never  be  undertaken  without  first 
securing  as  complete  a  provisional  hemostasis  as  possible.  Unless 
this  precaution  is  taken  the  hemorrhage  may  be  overwhelming  from 
the  very  outset.  In  such  case  it  is  impossible  to  distinguish  any- 
thing, and  the  sole  resource  is  to  apply  forceps  at  random,  running 
the  risk  of  tearing  the  vessel  and  increasing  the  hemorrhage,  or 
seizing  an  important  nerve,  with  the  most  serious  complications. 

After  preventive  hemostasis  has  been  secured,  the  hematoma  is 
laid  open  by  one  free  incision  and  rapidly  cleaned  of  clots. 

Permanent  hemostasis  is  the  next  step  to  be  accomplished.  Here 
arises  the  question  of  the  advisability  of  ligature.  It  has  been 
stated  already  that  in  extensive  wounds  ligature  of  a  main  artery 
does  not,  in  itself,  endanger  the  vitality  of  the  limb  to  a  great  ex- 
tent; the  same  can  not  be  said  with  reference  to  ligature  in  hema- 
toma.   Double  ligature,  after  the  evacuation  of  a  large  diffuse  hema- 


ABSTRACTS  OF  WAR  SURGERY  269 

toma,  in  the  case  of  certain  large  arteries,  is  followed  by  partial 
or  total  necrobiosis  in  nearly  one-third  of  the  cases.  Under  these 
circumstances  it  is  important  to  know  beforehand  whether  the  re- 
establishment  of  the  collateral  circulation  is  probable.  If,  after 
having  provisionally  checked  the  flow  of  blood  in  the  artery  for  a 
few  seconds,  no  signs  of  arrested  circulation  are  evident,  it  may  be 
hoped  that  the  circulation  will  be  reestablished.  This  may  be 
confirmed  by  means  of  a  small  incision  at  the  extremity  of  a  toe  or 
finger,  or  even  the  exposure  of  a  small  terminal  arteriole,  or  an 
artery,  such  as  the  dorsalis  pedis.  If  the  accompanying  vein  is 
compressed  and  its  distal  end  swells  rapidly  in  spite  of  the  occlusion 
of  both  ends  of  the  wounded  artery,  the  conclusion  is  obvious  that 
the  blood  continues  to  flow  into  the  limb  and  to  return  by  the  veins. 
Lastly,  when  blood  escapes  from  the  distal  end  of  the  wounded  ves- 
sel at  the  moment  when  the  forceps  are  removed  from  it,  the  col- 
lateral circulation  is  present  and  is  sufficient. 

If  this  triple  test  is  negative,  the  indications  favor  arterial  suture. 
Despite  the  difficulties  attendant  upon  arterial  suture  and  the 
limited  successful  resort  to  the  method  in  war  wounds,  Sencert 
believes  it  should  be  persisted  in.  The  great  success  which  has 
followed  its  use  in  the  treatment  of  aneurism  suggests  the  possi- 
bility of  like  success,  though  less  easily  accomplished,  in  the  treat- 
ment of  diffuse  hematomata. 

Tuffier  (Bull,  et  mem.  Soc.  de  Paris,  1917,  xliii,  No.  25,  1469) 
recommends  the  ligation  of  the  accompanying  healthy  vein  when 
one  of  the  larger  arterial  trunks  has  to  be  ligated.  It  is  a  well- 
demonstrated  fact,  he  says,  that  simultaneous  ligation  of  vein  and 
artery  does  not  increase  the  risk  of  ischemia  and  gangrene.  More- 
over, English  statistics  show  that  ligature  of  the  larger  arterial 
trunks  is  in  a  general  way  followed  by  gangrene  in  40  per  cent  of 
cases,  and  that  this  percentage  drops  to  24  per  cent  in  the  cases 
where  vein  and  artery  are  simultaneously  ligated.  This  percentage 
difference  is  particularly  marked  in  the  case  of  the  popliteal.  Liga- 
ture of  the  popliteal  alone  gave  41.6  per  cent  gangrene,  whereas 
ligature  of  artery  and  vein  gave  only  21.5  per  cent  gangrene. 

The  treatment  of  medium-sized  or  small  hematoma  of  slow  growth, 
following  a  shell  wound,  resolves  itself  into  the  management  of  (1) 
a  hematoma  of  medium  size  recently  formed  and  easily  diagnosed, 
(2)  a  suppurating  wound  with  either  diffuse  secondary  hematoma 
or  secondary  hemorrhage. 

In  the  first  case  the  measures  called  for  are  provisional  hemostasis, 


270  ABSTRACTS  OF  WAR  SURGERY 

free  exposure  and  incision  of  the  hematoma,  and  treatment  of  the 
vascular  wound  as  outlined  above. 

In  the  second  case  the  problem  involves  the  treatment  of  sec- 
ondary hemorrhage.  The  first  operative  measure  is  the  free  ex- 
posure of  the  traumatized  area;  the  second,  the  isolation  of  the 
bleeding  vessel  and  its  ligature  above  and  below  the  opening.  If, 
because  of  the  condition  of  infected  traumatized  tissues,  this  is 
impossible,  ligature  at  a  distance  may  be  employed  as  a  last  re- 
source. 

The  treatment  of  hematoma  following  a  bullet  wound  is  by  in- 
cision of  the  hematoma  and  direct  hemostasia  of  the  vascular  wound. 
This  operation  should  be  performed  as  soon  as  the  hemostasis  is 
diagnosed,  whether  at  the  field  ambulance  the  next  day  or  at  the 
base  hospital  two,  three,  four,  or  five  weeks  later  if  it  has  only 
then  been  recognized. 

Treatment  of  wounds  of  arteries  without  hemorrhage,  whether 
caused  by  bullet  or  by  minute  shell  fragments,  escape  detection,  in 
the  vast  majority  of  cases,  both  at  the  front-line  stations  and  at  base 
hospitals.  It  is  not  until  later  that  certain  minor  functional 
troubles,  in  association  with  a  small  aneurism  or  an  aneurismal 
varix,  make  their  appearance. 

Perrenot  (loc.  cit.),  discussing  the  treatment  of  dry  wounds  of 
large  vessels,  holds  that  the  wound  orifice  should  be  ignored  and  a 
classic  incision  made  to  discover  the  vessels  involved.  The  incision 
should  be  large  enough  to  permit  thorough  examination.  When 
lesions  are  found,  treatment  is  the  same  as  in  other  wounds  of  the 
vessels.  Ligatures  should  be  used  rather  than  sutures,  owing  to 
the  contused  edges  and  the  necrotic  portions  of  vessels  excised. 

Alamartine  (loc  cit.)  emphasizes  the  necessity  of  early  opera- 
tions, which  should  be  performed  before  the  formation  of  an  aneur- 
ism ;  the  importance  of  the  minor  symptoms  which  often  reveal  the 
existence  of  a  vascular  injury ;  and  the  necessity  of  acting  by  direct 
operation  at  the  site  of  the  vascular  lesion  and  not  by  a  distant 
ligature. 

Neuberger  (loc.  cit.)  advocates  double  ligatures  placed  beyond 
the  obtunding  clot  in  wounds  of  the  ' '  mute ' '  type. 

Of  80  vascular  wounds  observed  by  Gregoire  and  Mondor  (Lyon 
chir.,  1917,  xiv,  625,  abstracted  in  Surg.,  Gyn.  and  Oost.,  1918)  23 
were  of  the  "silent"  variety.  In  these,  as  in  all  other  forms,  these 
surgeons  advocate  ligature  of  the  vessel  or  vessels  above  and  below 
the  site  of  injury.    They  do  not  favor  ligature  at  a  distance  except 


ABSTRACTS  OF  WAR  SURGERY  271 

in  eases  where  the  artery  is  deprived  of  its  sheath  for  a  certain 
length. 

Aneurism,  the  remote  consequence  of  untreated  vascular  lesion 
of  the  dry  kind,  has  received  a  great  deal  of  attention  in  the  litera- 
ture of  the  war,  which  has  witnessed  a  relatively  greater  number  of 
traumatic  aneurisms  than  any  previous  wars,  as  pointed  out  by 
Forgue  (Rev.  de  chir.,  Par.,  July-August,  1917).  Inasmuch  as 
their  treatment  under  war-time  conditions  differs  in  no  essential 
point  from  that  of  civil  practice,  it  will  not  be  considered  here  at 
length.  The  excellent  work  of  Forgue  on  arteriovenous  aneurism, 
however,  merits  mention.  The  ideal  treatment  for  arteriovenous 
aneurism,  he  says,  consists  in  operating  within  a  few  days  after 
the  reception  of  the  wound.  The  technic  is  then  simple:  The 
wound  is  enlarged  or  a  fresh  incision  is  made,  the  clots  are  turned 
out,  the  vessels  are  recognized  and  isolated,  and  the  wounds  in  the 
vessels  are  treated  as  lateral  rents  and  sutured.  In  practice  this 
method  of  treatment  is  exceptional  of  accomplishment. 

Usually  the  treatment  is  deferred  until  signs  of  aneurism  appear 
and  operation  is  done  to  prevent  the  appearance  of  the  later  dis- 
turbances. An  unfavorable  time  for  operating  is  the  second  and 
third  week,  because  at  that  time  the  surrounding  tissues  are  infil- 
trated with  inflammatory  exudation  and  the  technical  steps  are 
difficult.  The  best  time  is  at  the  end  of  the  fourth  week,  at  which 
time  the  inflammatory  reaction  has  subsided  and  mostly  disappeared 
and  there  has  been  no  time  for  the  formation  of  any  hard  scar 
tissue.  In  addition,  the  circulation  of  the  limb  has,  by  that  time, 
had  time  to  accustom  itself  to  the  new  conditions  and  the  danger  of 
resulting  gangrene  is  minimized,  if,  at  operation,  it  be  found  neces- 
sary to  tie  the  vessels  completely. 

The  exact  level  of  the  intravascular  communication  is  determined 
in  three  ways:  (1)  By  determining  the  exact  trajectory  of  the 
missile  between  the  points  of  entrance  and  emergence  of  the  bullet, 
or  the  point  of  entrance  and  the  position  of  the  projectile,  when 
there  is  only  one  wound;  (2)  the  point  of  maximum  projection  of 
the  tumor  when  the  latter  exists;  (3)  the  level  at  which  the  thrill 
and  bruit  are  loudest. 

Any  method  by  which  it  is  attempted  to  cause  coagulation  of  the 
blood  in  the  aneurism  is  useless,  likewise  ligature  of  the  artery  above 
the  aneurism.  This  method  has  not  any  effect  on  an  arteriovenous 
aneurism.  In  addition  there  is  usually  a  relative  anemia  in  the 
part  of  the  limb  below  the  lesion  and  ligature  of  the  artery  above 
may  cause  gangrene.    In  certain  cases,  as  in  the  carotid  and  jugular 


272  ABSTRACTS  OP  WAR  SURGERY 

with  large  tumor  formation  and  with  no  collaterals,  it  may  be  the 
only  method  possible. 

Ligature  of  the  artery  above  and  below  the  aneurism  is  con- 
demned except  in  segments  of  the  common  carotid  or  external  iliac, 
which  have  no  collateral  branches. 

The  methods  which  can  be  used  to  advantage  are  as  follows : 

1.  The  Four-ligature  Method. — The  artery  and  vein  are  ligated 
above  and  below  the  aneurism.  The  method  has  yielded  a  con- 
siderable number  of  successes  and  the  condition  for  its  efficacy  is  the 
absence  of  any  collateral  circulation  in  the  ligated  area.  The  three 
danger  localities  for  this  method  are  (a)  the  bifurcation  of  the 
common  carotid;  (o)  the  point  of  division  of  the  femoral  artery; 
and  (c)  the  branching  of  the  popliteal  into  the  tibioperoneal  and 
anterior  tibial  trunks. 

2.  To  guarantee  a  cure  one  must  extirpate  the  segments  of  vein 
and  artery  together  with  the  aneurism.  In  order  not  to  compro- 
mise the  circulation  as  short  a  segment  as  possible  should  be  excised. 
The  method  of  procedure  advised  is  as  follows : 

An  Esmarch  is  not  used  because  the  suppression  of  the  circula- 
tion in  scar  tissue  makes  it  difficult  to  recognize  the  vessels.  A 
long  incision  is  made — long  enough  to  uncover  the  entire  aneurism. 
One  goes  immediately  to  the  proximal  side  and  isolates  the  artery 
and  vein  in  healthy  tissue  and  immediately  it  is  surrounded  by  a 
provisional  ligature  which  is  tied  if  hemorrhage  makes  it  necessary, 
or  when  no  method  of  conservative  surgery  is  shown  to  be  avail- 
able. From  this  point  methodical  dissection  is  carried  on  along 
the  vessels  which  are  always  found  infiltrated  with  extensive  and 
dense  adhesions. 

When  the  structures  are  all  isolated,  and  in  certain  locations,  as 
at  the  root  of  the  neck  or  in  the  popliteal  space,  it  may  be  difficult 
or  impossible,  account  should  again  be  taken  of  conditions  and  it 
may  be  possible  to  be  conservative  and  retain  one  of  the  vessels. 
If  not,  the  whole  segment  is  excised. 

The  complications  to  be  feared  after  this  method  are : 

Secondary  hemorrhage.  The  best  preventive  is  a  rigid  asepsis  at 
the  time  of  operation. 

Gangrene  is  always  an  uncertain  factor,  and  its  occurrence  is 
reduced  to  the  minimum  in  the  upper  extremities,  and  in  young 
patients  with  healthy  arteries. 

Conservative  operations  are  always  to  be  chosen  when  possible. 
The  ideal  method  is  to  isolate  the  arteriovenous  communication, 
divide  it,  and  treat  the  two  openings  which  result  as  two  lateral 


ABSTRACTS  OF  WAR  SURGERY  273 

openings  which  are  closed  by  suture.  The  same  effect  is  secured 
by  isolating  the  communication  and  then  obliterating  it  by  ligature 
or  suture.  Bickham  described  the  method  by  which  the  communica- 
tion is  obliterated  by  suture  from  the  interior  of  one  of  the  vessels 
— a  transvascular  approach.  These  methods  are  most  advantageous 
at  the  divisions  of  the  carotid,  the  femoral,  and  the  popliteal  vessels. 

If  both  artery  and  vein  can  not  be  conserved  an  attempt  should 
be  made  to  retain  the  arterv.  The  vein  is  doubly  ligated  above  and 
below  and  the  segment  between  is  isolated  down  to  the  arterial 
communication ;  the  artery  is  then  compressed  above  and  below  by 
Crile  clamps,  the  venous  segment  is  cut  away,  and  the  opening  in 
the  artery  is  closed  by  a  lateral  suture.  If  a  lateral  suture  is  im- 
possible the  vessel  may  be  divided  and  an  end-to-end  suture  made 
provided  the  gap  is  not  too  large.  A  large  gap  can  be  made  good 
by  a  transplant  taken  from  the  saphenous  vein. 

Extirpation  of  the  pathological  structure  with  arterial  and  ven- 
ous segments  in  the  lower  limbs  has,  in  a  certain  number  of  the 
successful  cases,  resulted  in  edematous  conditions  which  have  in- 
capacitated them  for  infantry  duty. 

FURTHER  EXPERIENCE  WITH  ANEURISMS  IN  WAR, 
WITH  SPECIAL  REFERENCE  TO  SUTURING  THE  VES- 
SELS.— H.  von  Haberer.  Wien.  klin.  Wchnschr.,  1915, 
xxviii,  pp.  435,  471. 

Von  Haberer  reported  13  eases  of  operation  for  aneurism  in 
1914,  at  which  time  he  thought  ligation  of  the  artery  with  ex- 
tirpation of  the  sac  was  the  method  of  choice,  and  all  of  his 
cases  were  operated  upon  in  that  way.  A  little  later  he  had 
occasion  to  suture  the  artery  in  a  case  of  aneurism  of  the  com- 
mon carotid.  Since  then  he  has  had  28  additional  cases,  in  16 
of  which  he  did  ligation  and  extirpation  and  in  12  suture,  mak- 
ing a  total  of  42  cases,  29  ligations  and  13  sutures.  He  gives 
the  histories  of  the  last  of  28  cases,  and  concludes  that  suture  is 
the  operation  of  choice  in  all  cases  in  which  it  can  be  performed. 
In  many  cases,  however,  it  is  impossible  to  suture,  though  with 
added  experience  he  is  continually  extending  the  indications. 

Five  of  his  cases  were  lateral  suture,  once  on  the  common  car- 
otid, twice  on  the  subclavian,  once  on  the  axillary,  and  once  on 
the  tibialis  anticus.  The  case  of  aneurism  of  the  common  carotid 
was  infected,  but  in  spite  of  that  recovery  was  uneventful  and 
restoration  of  circulation  perfect.    Of  the  seven  cases  of  circular 


274  ABSTRACTS  OF  WAR  SURGERY 

suture  four  were  of  the  femoral  artery,  one  the  brachial,  and 
two  the  subclavian. 

From  his  total  of  42  cases  he  finds  that  the  results  were  better 
with  suture  than  with  ligation.  Among  the  29  cases  of  ligation, 
amputation  was  necessary  in  two,  and  one  patient  died  of  hemor- 
rhage from  erosion.  There  was  another  death,  but  this  patient  was 
in  such  bad  condition  that  death  can  not  be  attributed  to  the 
operation.  There  was  not  the  slightest  complication  in  any  of 
the  13  cases  of  vessel  suture,  in  spite  of  the  fact  that  some  of 
them  were  very  difficult  cases.  In  addition  to  the  infected  case 
mentioned  above  there  was  one  case  of  aneurism  of  the  femoral 
complicated  by  fracture  of  the  femur.  The  leg  was  placed  in 
extension  immediately  after  the  operation,  but  the  suture  held 
perfectly  and  there  was  no  interference  with  circulation  in  the 
leg.  In  one  case  of  aneurism  of  the  subclavian  the  sac  extended 
far  down  into  the  thorax,  and  it  was  so  difficult  to  get  at  that 
the  operation  took  three  hours ;  there  was,  moreover,  a  defect 
of  4  cm.  in  the  artery.  Considering  all  these  facts  the  result 
was  surprising.  The  author  has  tried  transplantation  of  a  piece 
of  vein  in  only  one  case,  in  which  it  was  unsuccessful. 

EXPERIENCE     WITH     VASCULAR     INJURIES.— P.     Graf. 
Beitr.  z.  klin.  Chir.,  1916,  xcviii,  p.  332. 

The  author  gives  his  experiences  derived  from  58  vascular  wounds 
observed  during  the  fighting  around  Warsaw. 

In  these  58  cases,  62  interventions  were  made ;  three  times  arrest 
of  hemorrhage  in  dying  men ;  43  ligatures ;  5  amputations  of  limbs ; 
8  suturings;  3  tamponings  under  narcosis.  The  general  mortality 
was  25  per  cent.  The  carotid  externa  was  ligated  six  times,  the 
carotid  interna  once,  and  the  maxillaris  externa  twice.  Tamponade 
was  absolutely  necessary  in  one  case.  There  were  15  ligatures  and 
3  suturings  of  the  subclavian,  brachialis,  and  cubitalis  for  arm 
wounds. 

In  the  leg  region  30  interventions  were  made  for  29  injuries ;  23 
ligatures — 5  amputations  for  infection;  5  vessel  suturings;  2  tam- 
ponades under  narcosis.  Of  these  interventions,  16  were  on  the 
femoralis — 11  ligatures,  6  suturings.  In  4  out  of  5  interventions 
on  the  popliteal,  infection  was  already  manifest,  and  in  the  fifth 
case  the  patient  died  of  secondary  hemorrhage  after  a  couple  of 
weeks.     In  the  tibialis  ligature  generally  stopped  the  hemorrhage. 


ABSTRACTS  OF  WAR  SURGERY  275 

In  one  of  these  cases  amputation  was  found  necessary  and  the  pa- 
tient died  after  a  few  days  owing  to  loss  of  blood  from  the  stump. 

Eight  arterial  suturings  were  done  without  any  subsequent  sec- 
ondary hemorrhage,  infection,  or  death.  The  author's  experience 
leads  him  to  think  that  vascular  injuries  coming  to  the  field  sur- 
geon are  under  all  circumstances  to  be  considered  as  life  endanger- 
ing. In  only  the  minority  can  a  smooth,  infection-free  encapsula- 
tion of  the  blood  outlet  be  obtained;  and  by  the  development  of 
aneurisms  bleeding  may  continue  for  weeks.  Every  secondary 
hemorrhage,  even  if  slight,  makes  an  opening  up  of  the  bullet  tract 
imperative.  This  should  be  done  even  if  the  bleeding  ceases.  Later 
hemorrhages  may  be  expected  with  certainty.  Therefore,  it  is  al- 
ways best  under  narcosis  to  lay  bare  the  larger  vessels  in  suspected, 
and  particularly  in  infected,  cases. 

For  clean  wounds  suture  of  the  vessels  is  the  best  procedure; 
and  even  slightly  infected  cases  may  be  sutured,  when  the  external 
wound  is  well  trimmed.  The  vessel  must  be  clearly  separated  away 
from  the  cavity  by  muscle-suturing. 

Ligature  of  the  larger  vessels  must  be  kept  up  for  two  or  three 
weeks,  especially  when  the  collateral  blood  flow  can  be  regulated 
and  checked  by  a  proper  disposition  of  the  limb. 

Hyperemia  and  the  procedure  of  Moszkowicz  are  adaptable  when 
there  is  a  question  of  the  development  of  collateral  circulation. 


JOINTS. 

PRACTICAL  POINTS  ON  THE  USE  OF  IMMOBILIZATION  IN 
WAR  SURGERY.— Rev.  of  War  Surg,  and  Med.,  April,  1918, 
i,  No.  2. 

Since  much  uncertainty  exists  in  the  minds  of  civil  surgeons 
when  first  plunged  into  the  whirl  of  war  surgery  as  to  the  reason 
for  many  of  the  accepted  procedures,  the  Division  of  Orthopedic 
Surgery  presents  the  following  discussion  of  practical  points  in 
the  technic  of  immobilization.  During  his  student  days  one 
learned  that  certain  diseases  require  a  prescribed  course  of  treat- 
ment, but  too  often  the  general  principle  underlying  the  specific 
case  was  not  recognized.  Methods  familiar  enough  in  civil  life 
are  not  available  in  war,  and  the  man  accustomed  to  follow  rou- 
tine treatment  and  ungrounded  in  the  fundamental  principles 
upon  which  that  treatment  is  based  finds  himself  at  a  great  dis- 
advantage. 

Many  of  the  everyday  methods  of  war  surgery  are  the  result, 
not  of  facts  learned  in  the  classroom  or  the  civil  hospital,  but  of 
the  necessity  of  applying  well-known  principles  with  the  help  of 
limited  material.  In  no  branch  of  work  is  this  better  shown  than 
in  the  methods  employed  to  fix  or  immobilize  wounds  for  trans- 
portation or  for  convalescence  in  hospital. 

Realization  of  the  importance  of  fixation  was  not  appreciated 
by  surgeons  during  the  early  days  of  the  war.  For  example,  frac- 
tured thighs  were  often  moved  considerable  distances  without 
splints.  The  result  was  an  extraordinary  mortality  in  these  cases, 
80  per  cent  at  times.  Such  alarming  statistics  called  for  investi- 
gation, and  thighs  were  immobilized  in  the  trenches  with  a  re- 
sulting decrease  of  50  per  cent  in  the  mortality. 

Conditions  met  in  war  which  demand  immobilization  may  be 
roughly  classed  as  (a)  fractures,  (b)  joint  injuries,  (c)  injury  to 
periarticular  tissue,  (d)  injury  to  muscle,  nerve  and  other  soft 
tissue. 

The  objects  to  be  achieved  are:  (1)  Rest,  one  of  the  most  im- 
portant factors  in  the  cure  of  injury  or  disease ;  (2)  correct  posi- 
tion of  wounded  parts,  to  avoid  subsequent  deformity  and  main- 
tain function;  (3)  comfort  of  the  patient. 

276 


ABSTRACTS  OF  WAR  SURGERY  277 

Immobilization  is  secured  by  fixation.  Fixation  may  be  denned 
as  the  process  of  securing  rest  or  immobility  of  an  injured  or 
diseased  part  of  the  body  in  any  desired  position.  It  is  accom- 
plished by  splinting  or  traction,  or  by  the  two  combined. 

There  are  certain  well-known  forces  to  be  met  in  applying  fixa- 
tion to  an  injured  limb  :  (a)  gravity  exerts  a  deforming  tendency 
in  a  downward  direction  and  requires  support  from  below  for  its 
correction;  (b)  muscular  spasm  acts  constantly  to  shorten  the 
leg,  creating  pressure  on  joint  surfaces  or  overriding  of  frag- 
ments; (c)  the  uneven  pull  of  counterbalancing  groups  of  mus- 
cles causes  angular  deformity  at  the  seat  of  the  lesion. 

While  enumeration  of  these  familiar  facts  seems  puerile,  it  is 
done  for  the  sake  of  laying  stress  on  the  fact  that  the  basic 
principles  of  immobilization  demand  that  all  forces  be  kept  con- 
stantly in  mind  while  applying  fixation  apparatus.  Materials  and 
appliances  employed  in  civil  practice  are  often  not  available.  It 
is  essential  at  all  times  to  keep  the  principle  in  mind  and  adapt 
the  means  at  hand  to  carry  out  the  required  principle  cor- 
rectly. 

Particular  stress  should  be  laid  on  the  distinction  between  the 
two  methods  used  to  overcome  these  deforming  forces  and  secure 
fixation.  By  means  of  splints  physiological  rest  is  secured  and 
position  is  maintained.  But  the  use  of  splints  alone  only  partially 
relieves  muscular  spasm.  This  spasm  produces  constant  pressure 
on  diseased  joint  surfaces  or  causes  overriding  in  case  of  frac- 
ture. Therefore  another  principle  must  be  applied  to  overcome 
this  pathological  condition— the  principle  of  traction. 

Splints. — It  is  evident  that  the  vast  variety  of  splints  in  use  in 
civil  practice  is  out  of  the  question  in  war.  Moreover,  the  oppor- 
tunity to  manufacture  splints  to  measure  for  the  individual  is 
impossible.  To  eliminate  wasted  effort  the  value  of  splints  must 
be  carefully  tested  for :  (a)  efficiency;  (b)  simplicity;  (c)  adap- 
tability for:  (1)  easy  access  to  wounds;  (2)  facility  in  transporta- 
tion. 

The  efficient  splint  must  be  capable  of  easy  and,  above  all, 
speedy  application  and  must  give  adequate  fixation.  Time  is  of 
the  utmost  importance  in  the  overwhelmingly  heavy  work  often 
encountered  during  severe  fighting. 

Simplicity  is  essential  from  the  point  of  view  of  supply. 
Splints  must  be  easy  to  manufacture,  economical  in  the  matter 
of  materials  used  in  their  construction,  and  must  pack  well  and 


278  ABSTRACTS  OF  WAR  SURGERY 

bear  transportation  and  rough  handling  without  breakage  or 
injury.  There  should  be  no  loose  keys  or  wrenches  to  be  lost, 
no  mechanical  adjustments  or  screw  threads  to  get  out  of  order 
or  to  become  useless  from  rust.  Iron  wire  splints  have  been  found 
to  fulfil  these  requirements  better  than  those  of  any  other  ma- 
terial and  most  of  the  splints  now  in  use  are  of  this  kind.  The 
splint  must  also  be  simple  in  the  manner  of  its  application.  Fre- 
quently bearers  or  comparatively  unskilled  assistants  are  called 
on  to  apply  them  and  the  principles  involved  in  their  use  should 
be  such  as  are  easily  grasped. 

Adaptability  should  be  considered,  at  the  front,  in  relation  to 
transport ;  at  the  base,  for  ease  of  access  to  wounds.  Wire  splints 
are  best  adapted  for  both  purposes.  Many  splints  can  be  used  for 
more  than  one  type  of  lesion.  Other  things  being  equal,  the  more 
injuries  for  which  a  single  splint  can  be  used,  the  better  adapted 
it  is  for  war  work.  It  is  of  great  importance  to  reduce  the  variety 
of  splints  used  to  the  lowest  efficient  minimum. 

In  this  connection  it  is  well  to  point  out  that  conditions  often 
arise  which  exhaust  the  local  supply  of  splints.  The  ingenious 
medical  officer  must  constantly  improvise  substitutes  from  boards, 
wire,  or  other  materials  at  hand.  Too  much  emphasis  can  not  be 
laid,  therefore,  on  the  importance  of  a  knowledge  of  the  basic 
mechanical  and  surgical  principles  involved  in  their  construction 
and  use. 

There  is  another  point,  perhaps  too  often  overlooked  in  dis- 
cussing splints.  In  the  great  majority  of  cases  wounds  are  mul- 
tiple, owing  to  the  extensive  use  of  high  explosives.  Treatment  is 
suggested  for  single  wounds  which  is  frequently  impossible  to 
carry  out,  and  here  again  the  surgeon's  ingenuity  will  be  taxed 
to  adapt  the  dressing  to  the  individual  emergency.  Cases  may 
eome  down  with  a  fractured  thigh  and  20  or  30  flesh  wounds 
sprinkled  over  the  thigh,  leg,  and  foot.  The  problem  of  apply- 
ing adequate  traction  is  a  difficult  one  to  meet. 

In  the  application  of  splints  for  any  purpose,  but  particularly 
for  fractures  and  joint  injuries,  gentleness  must  never  be  for- 
gotten. A  very  real  danger  to  the  technic  of  the  war  surgeon 
is  that  he  will  become  careless  in  handling  wounds  and  callous 
to  the  suffering  he  may  be  causing  his  patient.  This  danger  is 
increased  by  the  extraordinary  endurance  and  stoicism  of  the 
wounded  soldier,  in  very  marked  contrast  to  most  of  the  cases 
met  in  civil    life. 


ABSTRACTS  OF  WAR  SURGERY  279 

The  splints  in  the  following  list  have  been  tested  by  long  use 
in  advanced  line  work  and  have  been  proved  of  value.  They 
fulfil  the  requirements  of  efficiency,  simplicity,  and  adaptability, 
and  they  are  all  of  use  in  hospital  work  as  well  as  for  cases  dur- 
ing transport,  thus  obviating  a  duplication  of  types  for  differ- 
ent zones  of  activity.  The  list  is  inclusive  and  covers  wounds  of 
any  part  of  the  body.  It  is  by  no  means  exclusive,  however,  as 
there  are  many  good  substitutes  of  proved  efficiency. 

They  are  classified  for  convenience  according  to  regions  of  the 
body.  It  is  not  necessary  to  describe  them,  as  the  full  specifi- 
cations for  each  splint  will  be  found  in  the  "Manual  for  Ortho- 
pedic Surgery"  or  the  "Splint  Manual  of  the  U.  S.  A.  Commis- 
sion Abroad." 

It  is  desirable  again  to  stress  the  point  that  these  splints  are 
not  mandatory  but  are  given  as  examples  of  appliances  that 
embody  correct  principles. 

Splints  For  Use  in  the  Advance  Zone. — Trenches,  Regimental 
Aid  Posts,   Advanced   Dressing   Station,   Field   Hospital. — 

/.     Upper  Extremity. — 

1.  Hand  and  forearm  wounds : 
Straight  or  coaptation  splints  of — 

(a)  Standard  sheet  iron,  20  gauge,  12,  16,  and  20-inch  lengths. 

(b)  Splint  wood  or  slats  from  bully  beef  boxes. 

(c)  Wire  gauze,  6  by  36-inch  lengths. 

2.  Elbow,  arm  and  shoulder  wounds: 

(a)  Thomas  traction  arm  splint. 

(b)  Jones  humerus  traction  splint. 
II.    Lower  Extremity. — 

3.  Forefoot  wounds.    Jones  rectangular  foot  splints. 

4.  Foot,  ankle  and  lower  leg  wounds. 

(a)  Jones  combined  ankle  and  lower  leg  splint. 

(b)  Posterior  leg  splint  with  straight  coaptation  splints. 

(1)  Posterior  splint  of  wood. 

(2)  Cabot  posterior  wire  splint. 

5.  Knee  and  thigh  wounds  : 

(a)   Thomas  traction  leg  splint. 

6.  Hip  and  pelvis  wounds : 

(a)  Long  Liston  splint. 

(b)  Straight  "bed  slat"  splint.  ,     :, 

7.  Spinal  wounds. 


280  ABSTRACTS  OF  WAR  SURGERY 

Exhaustive  comment  on  the  principles  embodied  in  these  splints 
and  the  method  of  their  application  is  out  of  place.  One  splint, 
however,  the  Thomas  traction  splint,  will  be  considered  as  illus- 
trating all  the  essential  principles  required.  Previous  to  the  war 
this  splint  was  in  common  use  among  orthopedic  surgeons  for  the 
immobilization  of  the  knee  joint,  the  function  for  which  its  orig- 
inator designed  it.  At  present  it  is  used  in  the  war  areas  for 
fractures  of  all  long  bones  and  injuries  to  the  joints  of  both 
upper  and  lower  limbs.  The  splints  for  leg  and  arm  are  the  same, 
except  for  size  and  the  obliquity  of  the  ring  on  the  leg  splint,  its 
position  in  relation  to  the  long  axis  of  the  arm  splint  being  at 
right  angles.  These  are  destined  to  remain  as  important  resources 
of  the  surgeon  after  the  war.  They  are  employed  to  maintain 
direction  or  position  of  the  limb  by  their  splinting  function,  and 
fixed  distance  by  their  traction  principle. 

Splints  of  the  Hodgen  and  Blake  types  are  modifications  of  the 
Thomas  splint.  In  them  position  alone  is  secured;  traction  de- 
pends on  additional  apparatus  and  has  the  advantage  of  supply- 
ing an  actual  extension  or  lengthening  force  more  effective  in 
overcoming  the  pressure  on  joint  surfaces,  or  the  overriding  of 
fractures,  than  the  fixed  distance  principle.  The  Thomas  splint 
may  be  modified  to  serve  the  same  purpose.  The  posterior  half  of 
the  ring  may  be  cut  away  with  a  hack  saw,  transforming  it  into 
the  Hodgen  type  of  splint,  or  extension  may  be  applied  to  the 
Thomas  splint  itself  after  securing  fixed  distance  by  leg  traction 
and  counter  bearing  of  the  ring  on  the  ischial  point  of  support. 

The  splinting  principle  is  secured  by  means  of  slings  of  non- 
elastic  material  hung  from  the  uprights  forming  a  retaining  gut- 
ter in  which  the  limb  lies  relaxed.  Coaptation  splints  may  be 
added,  but  a  bandage  serves  the  same  purpose  and  makes  dress- 
ings much  less  disturbing  to  the  wound.  These  slings  are  often 
made  of  sheets  of  perforated  zinc  or  of  wire  gauze.  In  practical 
use  strips  of  rubber  sheeting  three  inches  wide  will  be  found  as 
effective  and  more  adaptable  to  the  contour  of  the  limb.  They 
are  waterproof,  easy  to  keep  clean,  nonelastic  and  strong. 
Whereas  the  metal  is  difficult  to  fit  accurately  and  alter  as 
needed,  these  strips  are  easily  and  rapidly  adjusted.  They  are 
fastened  to  the  uprights  most  conveniently  by  clips  of  steel  (the 
ordinary  paper  clip)  or  by  wooden  spring  clothes-pins,  which  are 
always  available.  Safety  pins  or  lacings  may  be  substituted  if 
necessary  or  desirable.  The  narrow  strips  of  sheeting  are  more 
useful  for  severe  cases,  as  they  make  dressings  easy.  Unclipping 


ABSTRACTS  OF  WAR  SURGERY  281 

one  or  more  of  the  strips  does  not  alter  the  position  of  the  limb 
and  a  dressing  can  be  done  through  the  opening  thus  provided. 
For  Carrel  dressings  their  waterproof  qualities  are  of  the  great- 
est value. 

Before  applying  the  splint  it  may  be  bent  to  conform  to  the 
variations  in  the  line  of  direction  of  the  individual  limb,  as 
genu  valgus  or  varus,  and  about  15°  of  flexion  should  be  given 
opposite  the  knee  joint.  This  flexion  can  be  greatly  increased 
to  meet  the  requirements  of  a  double  inclined  plane  apparatus 
for  low  fracture  of  the  femur.  The  line  of  extension  may  be  car- 
ried in  any  direction  desired  by  flexing  or  abducting  the  hip 
joint. 

The  above  suggestions  account  for  correct  immobilization  by 
splinting  of  injuries  to  the  limbs  save  in  two  particulars,  toe  drop 
and  wrist  drop.  Further  apparatus  must  be  supplied  for  these 
purposes.  A  foot  wire  is  made  to  fit  the  uprights  and  extend 
like  an  arch  several  inches  above  the  toes.  To  the  keystone  of 
this  arch  the  foot  is  suspended  and  then  bandaged  to  the  uprights 
of  the  arch,  securing  fixation  in  all  directions.  For  the  hand,  a 
cock-up  splint  should  be  added.  Applications  of  the  suspension 
apparatus  to  the  foot  are  often  secured  by  carrying  the  bandage 
under  the  heel.  This  is  a  method  involving  some  risk.  It  must 
be  borne  in  mind  that  in  severe  wounds  circulation  of  the  limb 
is  often  greatly  impaired.  Pressure  sores  develop  with  extraor- 
dinary readiness.  Any  method  that  brings  even  mild  contin- 
uous pressure  on  any  part  of  the  skin  is  to  be  avoided  with  great 
care.  The  most  generally  useful  method  of  support  is  by  means  of 
a  strip  of  gauze  or  flannel  glued  to  the  sole  of  the  foot  and  fas- 
tened to  the  arch  of  the  foot  piece,  after  which  the  bandage  is 
applied  for  lateral  fixation. 

Traction. — Traction  serves  a  double  purpose.  It  aids  fixation 
by  maintaining  the  limb  in  the  straight  line  of  pull  and  it  coun- 
teracts the  attractive  pull  of  muscles  due  to  their  normal  tone 
or  their  spasm  from  pathological  irritation.  The  second  and 
very  important  function  is  called  extension  of  the  muscles.  It 
acts  immediately  to  lengthen  a  limb  when  first  applied  and  more 
slowly  to  overcome  shortening  by  tiring  the  muscles.  From  this 
it  is  evident  that  traction  by  fixed  distance  as  provided  in  the 
Thomas  splint  is  less  efficient  than  traction  by  weight  and  pulley, 
which  acts  over  a  prolonged  period.  It  is  the  modified  use  of  the 
Thomas  splint,  combining  it  with  the  use  of  traction   (Balkan 


282  ABSTRACTS  OF  WAR  SURGERY 

frame),  that  has  made  it  of  such  very  great  value  in  the  treat- 
ment of  war  wounds  at  the  base  hospitals. 

The  practical  application  of  traction  has  occupied  the  thought 
of  military  surgeons  to  a  very  large  extent.  As  stated  above, 
the  skin  in  severely  wounded  limbs  is  very  sensitive  to  pressure. 
Efficient  traction  demands  strong  support  for  the  heavy  weights 
frequently  required.  Therefore,  great  care  is  needed  to  secure 
efficiency  without  damage  from  skin  pressure. 

Methods  may  perhaps  best  be  considered  under  the  two  heads, 
temporary  traction  and  permanent  traction. 

Temporary  Methods. — These  are  required  in  providing  for  front 
line  and  transportation  dressings.  They  are  needed  for  the  leg, 
the  arm,  and  the  trunk  in  spinal  injuries. 

The  materials  for  this  form  of  traction  are  adhesive  plaster, 
bandages,  folded  blankets,  as  pillows  for  spinal  extension,  splint 
supports  on  stretchers  to  give  proper  direction  to  the  traction,  etc. 
Ingenious  use  for  foot  traction  is  made  of  canvas  anklet,  nails, 
screw  eyes,  and  wire  tongs.  By  far  the  most  serviceable  and 
universally  obtainable  material  is  gauze  or  muslin  bandage.  At 
the  front,  both  ankle  and  wrist  may  be  used  for  the  application 
of  temporary  traction. 

The  bandage  for  ankle  traction  is  applied  outside  the  shoe, 
which  protects  the  skin  and  the  circulation  of  the  foot.  It  is 
well  to  cut  the  lacing  of  the  boot  and  apply  a  smooth  pad  of  sheet 
wadding  or  cotton  over  the  instep.  The  bandage  should  be  a 
doubled  piece  of  3  or  4  inch  gauze  or  muslin,  2  yards  long.  The 
middle  of  the  bandage  is  brought  around  behind  the  heel  just 
above  the  counter  of  the  shoe,  the  two  ends  are  carried  forward 
and  then  downward  under  the  shank  of  the  shoe,  crossing  each 
other  over  the  instep  and  under  the  shank.  The  ends  are  then 
brought  up  along  the  respective  sides  of  the  foot,  passed  under 
the  first  part  of  the  bandage  applied  just  back  of  the  malleoli,  and 
then  downward  to  the  cross  bar  of  the  splint  as  two  traction 
bands.  The  pull  should  be  taken  from  a  point  well  behind  the 
ankle  joint  to  prevent  any  tendency  to  cause  plantar  flexion  of 
the  foot. 

For  temporary  wrist  traction,  the  clove  hitch  is  most  satisfactory. 
It  is  a  simple  clove  hitch  made  with  doubled  bandage  and  takes  its 
grip  on  the  eminences  of  the  hand.  Bringing  the  knot  in  front  tends 
to  extend  the  hand,  and  there  is  no  danger  of  constriction  as  there^ 
is  in  the  use  of  a  slipknot. 


ABSTRACTS  OF  WAR  SURGERY  283 

In  either  case,  the  ends  of  the  traction  bands  are  brought  outside 
the  uprights  of  the  Thomas  splint,  one  above  and  one  beneath, 
wrapped  half  round  and  then  carried  to  the  cross  piece  where  they 
are  again  half  wrapped,  the  desired  traction  is  applied  and  the  ends 
tied  in  a  square  half  bowknot.  The  uprights  act  as  a  spreader  and 
the  more  familiar  type  of  separate  spreader  is  made  unnecessary. 

This  bandage  method  of  applying  temporary  traction  is  quite  suf- 
ficient for  rapid  work.  Several  substitutes  have  been  suggested  by 
ingenious  surgeons  but  they  have  the  disadvantage  of  introducing 
separate  small  parts  which  are  not  always  easy  to  keep  on  hand. 
Nails  have  been  driven  through  the  heel  of  the  shoe  and  traction 
bands  tied  to  the  projecting  ends.  This  is  unwise  as  it  involves  dis- 
comfort to  the  patient  from  the  hammer  blows.  Sharp  skewers  may 
be  passed  through  the  vamp  of  the  shoe  beneath  the  patient's  foot. 
This  causes  no  pain  but  involves  a  separate  piece  of  apparatus.  A 
pair  of  tongs  has  been  devised  to  grip  the  sole  of  the  shoe,  open  to 
the  same  criticism  of  adding  complication  without  sufficient  benefit. 
A  canvas  anklet  laced  up  the  front  of  the  foot  is  good  but  does  not 
possess  material  superiority  over  the  bandage. 

It  must  be  remembered  that  no  temporary  method  provides  grad- 
uated traction,  true  extension.  The  maintenance  of  fixed  distance  is 
the  only  object  attained.  To  correct  this  a  grave  mistake  has  been 
made  by  some  surgeons.  A  piece  of  rubber  tourniquet  has  been  sub- 
stituted for  the  traction  bands  and  attached  to  the  crosspiece  of  the 
splint.  There  is  no  way  of  gauging  the  pull  in  this  elastic  traction 
and  mishaps  have  arisen  from  its  use.  It  should  be  condemned.  In 
the  hospital,  elastic  traction  may  sometimes  be  of  service  where  it 
can  be  most  carefully  watched,  but  it  is  always  contraindicated  for 
transport  purposes. 

Permanent  Traction. — The  weight  and  pulley  method  has  dis- 
placed the  traction  methods  applicable  to  the  Thomas  splint  itself 
(fixed  distance  and  elastic  traction)  in  hospital  work.  This  is 
merely  the  familiar  Buck's  extension  principle.  Iron  weights  are 
rarely  available,  but  a  sand  bag  answers  every  purpose.  Pulleys 
have  to  be  improvised  at  times.  Methods  of  attaching  the  adhesive 
bands  to  the  skin  are  the  usual  Z-0  adhesive  plaster  and  various 
forms  of  glue.  Moleskin  is  quite  unnecessary.  Adhesive  plaster  is 
frequently  used,  but  has  been  superseded  in  the  hands  of  most  base 
hospital  surgeons  by  glue  and  bandage  methods.  There  are  two 
types  of  glue  in  use.  The  Heusner  and  Sinclair  glues  require  heat- 
ing, the  Venice  turpentine  glue  or  "Mastisol"  is  applied  cold.    The 


284  ABSTRACTS  OF  WAR  SURGERY 

hot  glues  have  deliquescent  substances  added  to  take  up  the  per- 
spiration, and  remain  firm  and  flexible  over  long  periods.  On  the 
whole,  their  use  is  more  common  than  that  of  Mastisol.  The  latter 
has  no  serious  drawbacks  and  when  properly  applied  has  a  holding 
power  equal  to  the  others.  The  writer  used  Mastisol  whenever 
available.  It  must  be  kept  tightly  corked,  is  a  very  sticky,  rather 
thick  glue,  difficult  to  remove  from  hands  or  gloves  and  rather 
harder  to  apply  than  the  hot  glues.  But  its  great  advantage  lies 
in  the  fact  that  it  can  be  used  cold,  saving  annoying  delays,  not 
rarely  encountered  in  the  use  of  the  others.  There  is  no  danger 
of  burning  the  patient,  a  very  real  advantage  as  many  cases  of 
serious  burns  have  resulted  from  the  careless  or  too  hasty  use  of 
the  hot  glues.  Mastisol  sets  more  slowly  than  the  others,  10  min- 
utes being  necessary  for  firm  adhesion.  But  light  traction  may  be 
applied  as  soon  as  the  bands  are  bandaged  on  and  this  may  soon 
be  increased.  The  glue  also  has  the  advantage  that  the  part  does 
not  have  to  be  shaved  as  it  does  if  adhesive  is  used.  The  applica- 
tion of  the  glue  with  upward  strokes  of  the  brush  is  advised  to 
avoid  pull  on  the  hair. 

Glue  adhesion  is  effective  for  two  to  four  weeks,  sometimes  even 
longer.  Skin  lesions  beneath  the  traction  bands  are  of  rare  occur- 
rence compared  with  their  relative  frequency  under  adhesive 
plaster.  The  patients  do  not  complain  of  discomfort  while  wearing 
them.  Their  removal  is  very  easy.  Hot  water  washes  off  the  heated 
varieties;  turpentine  or  petrol  removes  the  Mastisol. 

In  the  many  cases  of  multiple  wounds  where  the  skin  of  the  leg 
is  involved  traction  bands  can  not  be  applied  to  the  leg.  In  these 
cases  mechanical  means  must  be  employed.  The  most  common 
methods  make  use  of  the  Steinmann  pin  under  the  Tendo  Achilles, 
taking  a  bearing  on  the  calcis;  or  tongs  in  the  condyles  of  the 
femur.  In  spite  of  the  fact  that  all  wounds  are  septic,  these  ap- 
pliances have  been  used  very  commonly  and  complications  from 
infections  are  not  at  all  frequent.  The  patient  is  surprisingly  com- 
fortable and  fair  extension  may  be  secured.  Special  gentleness  is 
needed  in  doing  dressings  and  the  nurses  and  orderlies  should  be 
cautioned  in  their  care  of  these  cases. 

Traction  methods  by  means  of  clamps  applied  to  the  bone  frag- 
ments have  been  tried  in  cases  of  fracture,  but  the  danger  of  sepsis 
has  proved  too  great  to  make  interference  with  bone  desirable  be- 
yond the  point  of  absolute  necessity. 


ABSTRACTS  OF  WAR  SURGERY  285 

WOUNDS   OF  JOINTS.— Rev.  of   War  Surg,  and  Med.,  April, 
1918,  i,  No.  2. 

One  of  the  almost  dramatic  surgical  surprises  of  the  war  has  been 
the  demonstration  that  joint  synovia  tolerate  and  even  dispose  of 
infection  to  a  degree  not  hitherto  suspected.  This  fact  naturally 
has  an  important  bearing  on  establishing  principles  for  treating 
joint  wounds. 

In  general,  the  treatment  of  joint  wounds  is  well  covered  by  the 
conclusions  reached  at  the  Interallied  Surgical  Conference  (March 
and  May,  1917),  which  are  as  follows: 

1.  At  the  dressing  station  wounds  of  the  joints  should  be  immo- 
bilized with  great  care,  in  an  appropriate  apparatus. 

2.  At  the  clearing  station,  all  injured  joints  in  which  the  wound 
is  extensive,  the  joint  tissues  are  lacerated,  or  the  missile  is  retained, 
and  especially  when  a  fracture  is  present,  should  be  operated  upon, 
if  possible,  in  the  first  six  or  eight  hours.  The  French  surgeons 
extend  this  rule  to  all  cases,  except  certain  bullet  wounds  with  a 
punctiform  orifice  and  without  fracture. 

3.  Radioscopy  is  indispensable  in  every  case. 

4.  The  operation  should  include  a  wide  aseptic  arthrotomy  with 
excision  of  the  track,  complete  exploration  of  the  joint,  systematic 
removal  of  foreign  bodies  and  splinters,  and  cleaning  and  curetting 
of  the  lesion  in  the  bone.  This  should  be  followed  either  by  com- 
plete closure,  or  by  closure  of  the  capsule  with  superficial  drainage. 
A  compressing  dressing  should  be  applied. 

5.  Resection,  typical  or  atypical,  should  only  be  practiced  when 
there  is  considerable  damage  to  the  bone.  In  the  knee  the  opera- 
tion should  be  primary,  whereas  in  the  elbow  and  shoulder  second- 
ary operation  is  preferable. 

6.  In  severe  suppurative  arthritis,  the  first  measure  should  be  a 
wide  arthrotomy  with  complete  immobilization  and  progressive  dis- 
infection of  the  wound.  If  this  treatment  fails,  then  resection 
should  be  practiced,  with,  at  first,  separation  of  the  articular  sur- 
faces by  extension.  In  very  grave  cases  immediate  resection  is 
required. 

Recent  publications  on  knee-joint  injuries  by  Kellog  Speed,  E. 
Tissington  Tatlow,  J.  R.  Judd,  R.  Mosti,  and  F.  Achille,  furnish 
adequate  material  from  which  one  may  draw  rational  conclusions 
regarding  the  present  status  of  joint  surgery.  Speed's  article  was 
submitted  as  a  report  to  the  Surgeon-General,  embodying  his  ex- 


286  ABSTRACTS  OF  WAR  SURGERY 

periences  on  the  western  front.  The  papers  by  Mosti  and  Achille 
were  abstracted  from  the  Italian  by  Surgery,  Gynecology  and  Ob- 
stetrics. 

Speed  reports  that,  in  the  light  of  the  results  of  recent  experi- 
ence, the  soldier,  after  a  knee-joint  injury,  should  be  splinted  at 
the  first  dressing  post  and  not  allowed  to  walk  on  the  leg.  All 
operations  should  be  done  at  the  casualty  clearing  stations,  within 
24  hours  after  reception  of  wound,  when  possible,  better  within  8 
hours.  When  this  arrangement  is  not  possible,  as  under  severe 
battle  circumstances,  the  following  types  of  knee  injury  may  be 
evacuated  at  once : 

1.  The  wound  that  shows  no  inflammation,  is  quiescent,  and 
lacks  pain. 

2.  Small  clean  wounds  of  entrance  and  exit,  or  entrance  alone, 
probably  caused  by  rifle  bullet. 

3.  "Wounds  with  no  serious  bone  or  blood  vessel  complication. 

4.  Foreign  body  not  evident  and  joint  not  painfully  distended. 
Wounds  of  the  posterior  aspect  of  the  knee  are  more  favorable 

for  transportation — they  drain  out  by  gravity.  On  the  anterior 
aspect  they  may  drain  into  the  knee  during  the  journey.  The 
Thomas  splint,  with  extension  and  flannel  bandages  from  toe  to 
thigh,  should  be  used. 

Types  of  knee  injury  to  be  retained  at  the  casualty  clearing  sta- 
tion are:  (1)  Those  complicated  by  serious  bone  or  blood  vessel 
injury;  (2)  distended,  painful  joint,  or  early  signs  of  septic  in- 
flammation; (3)  foreign  body  visible  or  palpable  after  it  has 
opened  joint;  (4)  large  superficial  wound  generally  caused  by 
shell  fire,  opening  into  the  joint.  Sepsis  is  certain  to  spread  into 
the  joint  and  immediate  operation  is  wanted. 

Early  operative  treatment  is  either  radical  or  conservative. 

Radical. — Amputation  is  advised  if:  (1)  Severe  blood  vessel  in- 
jury exists — even  a  large  hematoma,  with  probable  infection  in  the 
popliteum;  (2)  severely  comminuted  fractures  into  the  joint 
exist;  (3)  gas  infections  of  the  periarticular  tissues  are  present; 
(4)  sepsis  has  already  set  in,  and  the  patient  is  in  poor  general 
condition.  Resection  is  advised  if  a  comminuted  fracture  leaves 
little  normal  joint  surface.  Most  of  these  result  later  in  amputa- 
tion— only  those  resected  very  early  do  well. 

Conservative  treatment  is  reserved  for  the  penetrating  and 
through-and-through  wounds,  even  in  the  presence  of  fracture  not 
sufficiently  extensive  to  indicate  resection  or  amputation.  If  the 
patella  is  shattered  it  is  removed,  its  periosteum  is  spared,  and  the 
synovial  membrane  is  closed  if  possible.    If  a  foreign  body's  pres- 


Abstracts  of  war  surgery  287 

ence  is  even  suspected,  the  patient  should  not  be  operated  upon 
until  there  are  skiagrams  in  both  lateral  and  anteroposterior  planes. 
Every  knee-joint  gunshot  should  be  operated  on  if  time  and  cir- 
cumstances permit.  The  most  innocent  appearing  may  lead  to 
serious  trouble.    The  technic  recommended  is  as  follows: 

1.  Careful  skin  shaving  and  disinfection.  The  leg  should  be 
held  up  off  the  table  by  an  overhead  swing. 

2.  The  track  of  the  missile  is  completely  and  slowly  excised  with 
a  sharp  scalpel — no  scissors.  Sliding  of  the  tissues  over  each  other 
is  avoided  and  the  contused  edges  are  removed  in  one  piece.  Suffi- 
cint  skin  opening  is  made  to  permit  access  to  the  foreign  body  or 
joint  surface.  Fresh  towels  and  instruments  are  then  displayed. 
No  fingers  or  instruments  are  inserted  through  the  soiled  wound 
into  the  joint — not  only  may  infection  be  carried  in,  but  the  foreign 
body  may  be  pushed  into  an  inaccessible  area.  The  foreign  bodies 
and  comminuted  bone  are  removed ;  the  synovial  surface  should  not 
be  sponged,  irrigated,  or  exposed  for  any  greater  period  of  time 
than  necessary.  It  matters  little  about  the  length  of  the  skin  in- 
cision, but  the  amount  of  skin  removed  should  be  sparing  to  avoid 
undue  tension  in  the  closure.  Skin  plastics  may  be  performed.  If 
the  foreign  body  is  buried  in  bone  it  is  removed,  taking  with  it  sur- 
rounding damaged  bone. 

3.  The  joint  may  be  irrigated  with  normal  salt  solution.  Vari- 
ous operators  use  ether,  flavine,  proflavine  or  eusol.  As  far  as  the 
author  can  tell,  the  solution  used  makes  little  difference.  Mechan- 
ical cleansing  without  joint  trauma  is  desired. 

4.  Closure  of  the  wound  in  layers.  The  synovia  is  closed  by 
stitching  to  bring  smooth  surfaces  only  in  contact,  and  the  super- 
ficial tissues  and  skin  are  closed  snugly  unless  there  is  great  edema 
and  contusion.  In  that  case  a  small  drain  may  be  put  down  to  the 
closed  synovial  surface,  not  into  the  joint.  If  the  synovia  can 
not  be  closed  a  gauze  pack  is  placed  down  to  its  surface.  Injec- 
tion of  formalin,  glycerine,  ether,  or  other  irritants  into  the 
closed  joint  is  of  doubtful  value. 

5.  A  Buck's  extension  is  attached  to  a  Thomas  splint  on  the 
leg  and  flannel  bandages  cover  all.  For  comfort  and  steadiness 
the  application  of  the  splint  should  be  exact — it  requires  skilled 
attention.  Most  patients  should  be  retained  24  to  48  hours  be- 
fore transportation.  Dressings  and  splint  are  not  disturbed  unless 
there  is  pain,  fever,  or  looseness. 

These  operations  take  from  40  minutes  to  2  hours.  When 
aseptic  healing  is  ensuing  and  the  joint  is  not  painful,  slight 


288  ABSTRACTS  OF  WAR  SURGERY 

passive  motions  may  be  started  in  the  second  week.  Should  the 
joint  become  distended,  should  temperature  rise  and  sepsis  seem 
starting,  an  aspiration  may  be  performed  to  decide  the  character 
of  the  intraarticular  fluid  and  to  obtain  a  culture.  Staphylococus 
infection  is  less  feared  than  streptococcus;  it  may  even  subside 
after  aspiration  with  rest.  Objections  to  aspiration  are  found 
in  the  wounding  of  the  synovial  surface  and  leakage  of  the  in- 
fected joint  contents  through  the  puncture  hole  into  poorly  re- 
sisting periarticular  tissues,  resulting  in  rapidly  spreading  sepsis. 
The  resistance  of  the  joint  surface  is  as  great  or  greater  than  the 
periarticular  tissues. 

The  reason  for  excising  these  wounds,  trimming  the  synovial 
edge,  and  irrigating  the  joint  after  bone  fragments  and  foreign 
body  are  removed,  is  found  in  the  fact  that  the  synovial  surface, 
if  given  a  chance,  is  almost  as  well  able  to  take  care  of  itself  as 
the  peritoneum,  and  the  resistance  of  the  joint  surface  is  greater 
than  it  was  formerly  believed  to  be.  After  trimming  and  irri- 
gating, the  joint  is  closed  snugly;  its  own  resistance  will  often 
do  the  rest.  A  joint  not  so  treated  ultimately  becomes  contami- 
nated by  the  extension  of  the  infection  when  the  unexcised  tract 
of  a  missile  which  has  become  septic  is  opened.  It  has  been 
proved  by  many  clinical  observations  that  joint  infection  may 
come  on  late,  after  the  wound  infection  has  developed  and  seeped 
into  the  articular  surface.  This  happened,  according  to  Speed, 
to  most  of  the  septic  joints  in  the  early  part  of  the  war.  By 
closing  the  joint  after  wound  excision,  if  infection  arises  extra- 
articularly  it  is  recognized  and  drained,  and  the  joint  is  saved. 
This  principle  is  employed  constantly  in  operations  on  fractures 
of  the  patella.  Splinting  prevents  motion,  hence  favors  an  early 
healing  of  the  sutured  synovia.  It  also  saves  the  patient  from 
pain  and  loss  of  sleep. 

When  septic  joint  threatens  to  follow  conservative  treatment 
or  no  operative  treatment  at  all,  Speed  coincides  with  the  view 
that  no  classical  drainage  of  the  knee-joint  is  satisfactory,  and 
that  joint  excision  after  infection  is  valueless.  Early  amputation 
is  advised.  It  gives  a  lower  mortality,  and  a  satisfied  living  pa- 
tent. A  drained  joint  may  result  in  a  useless  leg  which  is  removed 
within  a  year. 

Analysis  of  the  85  cases  in  the  series  reported  gives  the  follow- 
ing: The  synovial  lining  of  the  joint  was  opened  by  the  missile 
in  every  instance.     The  synovial  surface  alone  was  involved  in 


ABSTRACTS  OF  WAR  SURGERY  289 

42  instances,  of  which  three  were  amputated  (7  per  cent).  There 
were  bone  injuries  accompanying  43  knee  wounds,  of  which 
6  were  amputated  (14  per  cent).  Foreign  bodies  were  present 
in  the  joint  in  25  case's,  in  the  bone  in  18.  The  amputations 
numbered  9  (approximately  10  per  cent).  Six  of  these  had  com- 
plicating bone  injury.  The  foreign  body  was  removed  in  7.  The 
wounds  of  6  of  these  9  patients  were  excised  early  at  casualty 
clearing  stations  or  field  ambulances ;  1  was  excised  late  at  the 
base;  2  were  never  operated  upon.  In  addition  to  these  9  there 
were  three  patients  who  might  possibly  have  gone  on  to  ampu- 
tation later  in  England.  There  is  no  record  of  them  after  leav- 
ing the  base.  There  were  2  deaths.  Both  patients  suffered  bone 
injuries  at  the  knee.  One  died  from  a  gas  infection  of  the  arm, 
which  was  amputated,  the  knee  apparently  doing  nicely.  In  real- 
ity, then,  there  was  but  one  death  caused  by  the  knee  injury  (gen- 
eral sepsis,  no  secondary  operation). 

The  general  results  of  the  series  of  85  were :  Excellent  in  25 
instances,  good  in  36  instances,  fair  in  13  instances,  loss  of  limb 
in  9  instances,  death  in  2  instances. 

Technic  of  Subcrural  Pouch  Drainage  and  Inversion  Treatment. — 
In  July  and  August,  1917,  Speed  began  draining  these  septic 
knees  very  early,  according  to  the  following  technic :  Cultural 
proof  of  intraarticular  infection  having  been  obtained,  drainage 
is  instituted  at  the  earliest  stage.  Under  anesthesia  an  opening 
one  inch  long  is  made  in  the  mid-line  of  the  thigh  at  the  upper 
margin  of  the  pouch.  The  quadriceps  extensor  muscle  fibers  are 
separated  longitudinally  by  a  pair  of  Mayo  scissors,  and  the 
joint  and  synovial  surface  carefully  opened  through  its  upper  re- 
flection only.  The  lower  synovial  wall  should  not  be  damaged. 
A  medium-sized  rubber  tube  extending  just  into  the  joint  is 
sewn  in  place.  The  incision  around  the  tube  is  left  wide  open 
to  favor  secretion  running  out  and  not  backing  into  the  thigh 
tissues.  A  Thomas  splint  and  extension  are  applied,  the  leg 
being  supported  by  crosspieces  of  perforated  metal  both  anter- 
iorly and  posteriorly,  thoroughly  padded  and  so  bandaged  that 
the  portion  over  the  wound  can  be  removed  for  dressing  without 
loosening  the  splint.  The  patient  is  put  to  bed,  a  Balkan  frame 
is  rigged  over  him,  and  for  two  hours  night  and  morning  he  is 
turned  over  on  his  face.  Later  these  periods  are  extended  until 
he  can  lie  thus  for  hours  at  a  time. 

If  the  tube  clogs  with  pus  and  debris,  it  can  be  mechanically 


290  ABSTRACTS  OF  WAR  SURGERY 

washed  out  with  normal  salt  or  eusol  until  it  is  freely  open.  The 
joint  may  be  thus  partly  irrigated  if  desired.  "When  the  discharge 
becomes  serous,  pus  ceases,  and  temperature  falls,  the  tube  is  re- 
moved and  the  small  wound  is  allowed  to  heal,  the  joint  being  safe- 
ly started  on  its  own  resistance  looking  toward  recovery.  The 
splint,  of  course,  is  retained  until  the  joint  is  quiet  and  painless. 

Six  patients  have  been  treated  by  subcrural  pouch  drainage  and 
inversion  and  observed  over  a  long  period.  In  four  the  results  were 
very  good,  one  recovering  from  a  gas  infection  of  the  joint.  One 
had  a  doubtful  outcome  and  one  required  amputation. 

Speed  believes  that  there  is  a  distinct  field  for  this  type  of  treat- 
ment, which  necessitates  such  a  small  amount  of  operation  on  pa- 
tients who  would  otherwise  be  subjected  to  extensive  drainage,  in- 
cisions, and  prolonged  suppuration.  Patients  so  treated  should  be 
those  in  the  early  stage  of  joint  infection,  before  cartilage  erosion 
has  taken  place  and  before  the  infected  contents  of  the  joint  have 
mechanically  burst  or  pathologically  necrosed  through  the  synovial 
surface  to  set  up  a  suppurative  periarthritis. 

Some  of  the  points  made  by  Speed  are  in  keeping  with  the  prin- 
ciples guiding  the  treatment  of  war  wounds  of  the  joints  adopted 
at  the  Interallied  Surgical  Conference  given  above. 

Speed  advises  that  data  covering  knee-joint  injuries  should  be 
collected  under  the  following  heads: 

1.  Type  and  location  of  wound  related  to  a  transverse  line 
through  patella: 

(a)  Was  there  exit  and  entrance? 

(b)  Was  synovial  surface  alone  involved? 

(c)  Was  there  fracture  accompanying?     Which  bones? 

(d)  Was  foreign  body  present ?    In  joint?      In  bone? 

(e)  Was  joint  traversed  by  foreign  body? 

2.  Type  of  first  treatment: 

(a)  Where  given:     Field  ambulance?     Casualty   clearing 

station?    Base  hospital? 

(b)  Was  joint  opened  by  missile  or  by  operation? 

(c)  Was  joint  irrigated? 

(d)  Was  joint  bipped? 

(e)  Was  foreign  body  removed?     Or  bone  fragment? 

(f)  Was  joint  closed  by  sutures? 

(g)  Was  joint  left  open? 

(h)   Was  joint  drained  by  foreign  material,  e.  g..  gauze,  gut- 
ta-percha, tube? 

3.  Were  splint  and  extension  used? 


ABSTRACTS  OF  WAR  SURGERY  291 

4.  General  data: 

(a)  Condition  of  patient  on  admission? 

(b)  Joint  pain,  swelling,  redness,  discharge  (pus  or  syno- 

vial fluid)  ? 

(c)  Temperature  curve? 

( d )  Cultures  made  ?    Kesults  ? 

(e)  Was  joint  aspirated?    Drained? 

(f)  Other  secondary  operation? 

(g)  Condition  on  discharge  from  hospital? 
(h)  Probable  prognosis? 

Tatlow  reported  his  series  of  knee-joint  wounds  in  the  British 
Journal  of  Surgery  for  January,  1918  (p.  462).  The  cases  included 
in  the  series  were  treated  at  a  base  hospital  during  the  year  1917.  Of 
the  100  cases,  2  died,  both  after  amputation;  4  were  successfully 
amputated ;  9  were  successfully  resected ;  and  12  were  unoperated. 
The  remaining  73  were  evacuated  to  England,  after  operation  either 
at  the  base  or  at  the  clearing  station,  with  a  normal  temperature, 
and  either  healed  or  granulated  wounds,  or  at  most  a  small  dis- 
charging sinus. 

From  his  experience  with  this  series  of  cases  Tatlow  draws  the 
following  conclusions: 

1.  Early  operation,  if  the  procedure  be  radical  and  especially  if 
the  entire  capsule  can  be  sutured,  results,  in  94  per  cent  of  the  cases, 
in  a  sterile  joint,  and  therefore  in  a  successful  issue. 

2.  Where  a  pack  or  drain  is  used  down  to  a  tear  in  the  capsule 
or  to  a  cavity  in  bone,  the  results  can  never  be  depended  upon. 

3.  The  removal  of  missiles  from  the  joint  within  the  first  week, 
even  in  the  presence  of  sepsis  (other  than  that  due  to  the  strepto- 
coccus), can  be  followed  by  immediate  suture,  B.  I.  P.  P.  being  used 
to  aid  sterilization. 

4.  The  Carrel-Dakin  method  is  most  useful  for  the  treatment  of 
bone  lesions  or  septic  periarticular  conditions.  It  is  almost  impos- 
sible to  sterilize  a  severely  infected  joint  by  this  method. 

5.  In  the  presence  of  a  general  infection  of  the  joint  by  the  strep- 
tococcus, resection  gives  good  results,  even  when  performed  in  the 
second  or  third  week. 

6.  Cases  with  a  severe  bone  injury  should  be  treated  more  often 
than  they  are  by  an  immediately  primary  resection  of  the  joint  at 
the  clearing  station. 

Judd  (Surg.  Gyn.  and  Obstet.,  1918,  xxvi,  No.  2,  p.  139),  basing 
his  observations  on  personal  experience  among  French  wounded 


292  ABSTRACTS  OF  WAR  SURGERY 

extending  over  a  year,  and  upon  the  views  and  methods  practiced 
by  French  surgeons,  draws  the  following  conclusions: 

1.  Wounds  of  the  knee-joint  in  modern  warfare  maintain  the 
same  importance  and  gravity  that  have  existed  since  the  birth  of 
surgery. 

2.  The  resisting  power  of  the  synovia  and  ankylosing  tendencies 
vary  in  individuals. 

3.  In  the  presence  of  an  infected  projectile  and  infected  joint 
fluid,  the  synovia  may  still  be  uninfected  for  a  certain  period. 

4.  Fissures  extending  to  the  articular  surface  are  important  and 
are  often  unrecognized. 

5.  Secondary  infection  of  the  ankle  joint  sometimes  occurs  unex- 
pectedly and  is  a  grave  complication. 

6.  The  earlier  methods  of  noninterference,  drainage  tubes,  and 
wholesale  removal  of  bone  have  yielded  disastrous  results. 

7.  The  mortality  has  been  greatly  reduced  by  improved  methods 
of  treatment. 

8.  Perforating  wounds  traversing  the  joint  should  be  treated  by 
puncture,  compression,  and  immobilization. 

9.  For  wounds  with  foreign  bodies  included,  with  or  without  bony 
lesions,  early  intervention  is  the  secret  of  success. 

10.  The  new  era  in  knee-joint  surgery  calls  for  arthrotomy  within 
48  hours,  removal  of  projectile,  foreign  bodies  and  loose  fragments, 
excision  of  path  of  projectile,  cleansing  of  joint  and  suture  without 
drainage. 

11.  Extensive  bony  lesions  demand  primary  resection. 

12.  It  is  in  the  decision  as  to  what  cases  should  properly  be 
treated  by  the  new  era  method  and  what  cases  demand  resection  on 
account  of  the  extent  of  bony  injury  that  difference  of  opinion 
between  individual  surgeons  is  bound  to  exist. 

13.  From  all  points  of  view  vital  preservation  of  the  limb  and  its 
function  and  duration  of  hospital  stay,  the  results  of  the  improved 
method  are  vastly  superior. 

Mosti's  paper  (Policlinico,  Rome,  1917,  xxiv,  p.  458)  deals  only 
with  the  technic  of  arthrotomy  of  the  knee-joint.  He  advocates 
the  transpatellar  method  devised  by  Bougot  and  De  la  Rue  as  the 
most  rational  method  of  executing  arthrotomy  of  the  knee-joint  in 
war  surgery.  In  this  procedure  the  incision  is  vertical  and  median 
on  the  anterior  face  of  the  knee,  starting  from  the  lower  extremity 
of  the  patella  across  its  anterior  face  and  rising  above  it  for  about 
four  or  five  finger-widths  to  the  point  where  it  meets  the  subquadri- 
cipital  cul-de-sac.  But  the  method  is  too  multilating  owing  to  the 
fact  that  the  cutaneopatellar  strip,  left  free  until  complete  recov- 


ABSTRACTS  OF  WAR  SURGERY  293 

ery,  undergoes  a  very  marked  retraction  and  not  only  leaves  a 
large  deforming  scar  of  the  knee  but  also  a  very  notable  functional 
defect,  i.  e.,  the  abolition  of  movements  of  extension.  There  is 
interrupted  continuity  of  the  patellar  tendon. 

For  the  purpose  of  avoiding  these  undesirable  results  Mosti 
applies  a  continuous  extension  to  the  cutaneopatellar  strip,  using 
a  simple  procedure:  On  the  cutaneous  face  he  fixes  two  wide 
strips  of  adhesive  plaster.  The  two  free  ends  brought  together  are 
fastened  to  an  elastic  tube.  The  tube  is  fixed  to  the  end  of  a  metal- 
lic stirrup  fixed  in  the  part  of  the  immobilizing  plaster  cast  which 
corresponds  to  the  plantar  part  of  the  foot.  The  tube  is  kept  in 
slight  tension.  The  cutaneous  strip  thus  acquires  a  strongly  oblique 
position  and  the  articular  cavity  is  kept  gaping  so  that  the  Carrel 
method  can  be  applied.  When  a  relative  sterilization  of  the  articu- 
lar cavity  has  been  reached,  the  tendon  stumps  are  united  with 
catgut  by  a  tenorrhaphy  and  the  cutaneous  margins  sutured  with- 
out drainage.  This  is  easily  done  as  the  strips  have  preserved  their 
full  length  owing  to  the  traction  exerted  on  them.  In  general  the 
secondary  suture  can  be  attempted  from  the  tenth  to  the  fifteenth 
day. 

Mosti  has  adopted  this  method  for  some  time  past  in  the  ma- 
jority of  knee  wounds  with  the  best  results;  he  reports  some  typi- 
cal cases.  He  claims  that  the  transpatellar  arthrotomy  with  the 
modifications  made  by  him  is  applicable  to  every  type  of  knee 
wound,  no  matter  how  much  time  has  elapsed  since  the  injury. 
It  also  fulfils  other  conditions  which  can  not  be  satisfied  by  other 
methods.     He  sums  up  the  advantages  as  follows: 

1.  It  widely  exposes  the  greater  part  of  the  articulation,  thus 
giving  means  for  better  drainage. 

2.  It  enables  a  wide  exploration  of  the  articular  cavity  to  be 
made,  and  by  bringing  eventual  lesions  into  full  display,  facilitates 
the  operative  manipulation. 

3.  Elastic  traction  applied  to  the  cutaneopatellar  strip,  while 
keeping  it  in  a  strongly  inclined  position,  hinders  its  retraction, 
whatever  may  be  the  duration  of  the  treatment. 

4.  Secondary  suture  both  of  the  patellar  tendon  and  of  the  cu- 
taneous incision,  made  possible  by  the  prevention  of  retraction, 
allows  an  almost  complete  restoration  or  a  solid  ankylosis  in  the 
best  position.  It  obviates  the  large  and  deforming  scars  which  gen- 
erally result  from  other  methods. 

5.  It  is  almost  always  possible  in  this  method  to  conquer  sepsis 
in  the  shortest  possible  time,  and  secondary  resection  very  rarely 
becomes  necessary,  if  it  is  not  altogether  eliminated. 


294  ABSTRACTS  OF  WAR  SURGERY 

Achille's  experience  (Gazz,  d.  osp.  e.  d.  din.  1917,  xxxviii,  p. 
723)  in  the  military  hospital  of  Ravenna,  and  his  study  of  the 
results  obtained  by  others  as  reported  during  the  war,  leads  him 
to  think: 

1.  That  small  transfossal  wounds  of  the  knee  generally  heal  with- 
out intervention. 

2.  That  it  is  not  always  advisable  to  extract  small  projectiles 
buried  in  the  articular  head  without  serious  bony  lesions,  as  the  op- 
erative act  can  awaken  infective  processes  of  extreme  gravity. 
Careful  immobilization  and  watchfulness  ought  to  be  the  surgical 
aim  in  these  cases. 

3.  In  recent  lacero-contused  articular  wounds,  early  inter- 
vention, the  use  of  noncaustic  fluids  and  the  promotion  of  pro- 
teolysis by  hypochlorites  is  the  procedure  of  choice. 

4.  When  an  infective  process  is  evident,  the  existence  of  a 
fracture  of  the  articular  head  will  be  assured  by  radiographic 
examination,  as  well  as  the  presence  of  any  foreign  body.  Sim- 
ple arthrotomy  is  always  insufficient  to  dominate  an  infection. 
In  such  cases,  if  the  condition  of  the  patient  permits,  an  atypical 
resection  should  be  attempted,  using  the  low  curved  Mackenzie  in- 
cision; this  should  be  completed  by  the  excision  of  all  the  syno- 
vial and  by  removal  of  the  patella. 

5.  In  cases  of  infective  arthritis  not  complicated  by  osseous 
lesions,  when  a  wide  aggressive  arthrotomy  and  immobilization 
do  not  suffice  to  arrest  the  infective  process  and  there  is  a  threat 
of  sepsis,  there  should  be  a  recurrence  to  the  occlusive  plaster 
apparatus,  according  to  procedure  suggested  by  Ruggi.  This  is 
kept  in  place  from  15  to  20  days.  In  this  way  a  limb  otherwise 
doomed  will  often  be  preserved. 

6.  Amputation  of  the  thigh  ought  to  be  reserved  for  extreme 
cases  or  those  in  which  the  complication  of  an  ascending  infec- 
tive osteomyelitis  renders  any  attempt  at  preservation  vain. 

The  author's  statistics  cover  65  cases,  27  of  which  were  strongly 
infected  penetrating  wounds,  some  complicated  by  fracture  and 
retention  of  the  projectile.  "Wide  arthrotomy  was  practiced  in  all 
27  cases,  with  removal  of  foreign  bodies  and  arthrectomy  or  par- 
tial resection. 

Of  these  27  cases  14  healed  without  other  intervention;  one 
died  from  sepsis ;  12  had  secondary  amputation  of  the  thigh  with 
8  recoveries  and  4  deaths. 

There  were  4  cases  of  pyoarthrosis  with  existence  of  fracture 


ABSTRACTS  OF  WAR  SURGERY  295 

and  osteitis  of  the  articular  head.  All  were  treated  by  atypical 
resection,  removal  of  the  patella  and  synovial  sac.  Three  were 
cured;  one  had  secondary  amputation  of  the  thigh. 

There  were  2  cases  of  comminuted  fracture  of  the  articular 
head  with  acute  sepsis  due  to  grenade  injury  and  in  which  am- 
putation was  not  advisable ;  both  died.  The  remainder  of  the  56 
cases  recovered. 

ARTICULAR    GUNSHOT    WOUNDS.— Haller.     Bull,    et   mem. 
Soc.  de  chir.  de  Paris,  1916,  xliii,  p.  1404. 

Haller  reports  his  experience  based  on  74  cases  of  articular 
injuries  observed  by  him  in  the  field  ambulance  service  up  to  last 
March.    He  divides  these  lesions  into  four  varieties : 

1.  Articular  wounds  with  injuries  of  the  soft  parts  only. 

2.  Articular  reactions  in  diaphyseal  or  diaphyso-epiphyseal 
fractures  with  fissures  into  the  joint. 

3.  Articular  injuries  with  more  or  less  extensive  breakage  of 
the  articular  surfaces. 

4.  Large  disruptions,  destruction  of  the  joint  with  laceration 
of  the  muscles,  vessels,  and  nerves. 

A  different  method  of  treatment  has  been  adopted  for  each  of 
these  varieties.  For  the  first  group  Haller  after  disinfecting  the 
orifice  uses  immobilization  and  compression.  In  5  cases  of  knee- 
joint  injuries  such  treatment  sufficed.  In  2  of  these  cases  the 
projectile  remained  embedded,  and  in  2  other  cases  subsequent 
arthrotomy  was  necessitated  owing  to  infection. 

In  9  cases  of  the  second  variety  arthrotomy  was  done.  In  all 
these  cases  there  was  a  septic  reaction.  Haller  thinks  that  in 
certain  cases  simple  arthrotomy  does  not  suffice  and  that  an 
early  partial  resection  may  be  necessary ;  but  this  may  be  avoided 
by  a  minute  clearance  of  debris  and  wide  drainage  at  first. 

In  the  third  class  of  lesion  Haller  counsels  economic  resection 
limited  to  the  soft  parts  and  osseous  surfaces.  He  has  made  6 
such  interventions  in  the  shoulder,  11  in  the  elbow,  4  in  the  wrist, 
1  in  the  hand,  1  in  the  hip,  1  in  the  ankle,  4  in  the  foot,  and  7  in 
the  knee. 

In  10  cases  of  the  fourth  group  Haller  amputated  immediately. 

The  total  results  in  the  74  cases  give  15  deaths ;  50  patients,  or 
80  per  cent,  left  the  hospital  in  good  condition. 


296  ABSTRACTS  OF  WAR  SURGERY 

Articular  injuries  of  the  knee  treated  by  compression  and  im- 
mobilization were  cured  without  complication.  In  16  arthroto- 
mies  Haller  had  only  1  death,  a  case  of  suppurative  arthritis 
of  the  shoulder  with  fracture  of  the  humerus  operated  upon  the 
fifth  day  after  injury.  In  two  others  an  amputation  and  resec- 
tion respectively  were  necessitated  subsequently. 

Of  35  atypical  resections,  there  were  7  deaths  and  28  recoveries. 
The  deaths  occurred  generally  in  cases  that  had  other  complica- 
tions. The  results  in  these  resection  cases  gave  20  per  cent  mor- 
tality, 8.57  per  cent  of  necessary  secondary  operations  (amputa- 
tions), and  71.43  per  cent  of  recoveries  in  good  condition. 

Secondary  amputation  was  necessary  6  times  in  55  cases  of 
arthrotomy  or  resection.  Of  these  6  cases  4  recovered  and  2 
died.  The  immediate  amputations,  of  which  there  were  19,  gave 
12  recoveries  and  7  deaths. 

RESECTION  OF  THE  KNEE  TO  AVOID  AMPUTATION  OF 
THE  THIGH  IN  FRACTURES  OF  THE  KNEE.— Turner. 
Presse.  med.,  1915,  xxiii,  p.  227. 

Comminuted  fractures  of  the  knee  with  suppurative  arthritis 
are  very  severe  injuries,  but  Tuffier  thinks  amputation  of  the 
thigh  is  practiced  much  too  freely  in  such  cases.  Among  200 
patients  upon  whom  amputation  was  performed  at  Maison 
Blanche,  30  were  for  injuries  of  the  knee  by  rifle  bullets,  which 
is  the  least  severe  form  of  injury;  those  by  shells  and  shrapnel 
are  much  worse. 

Of  74  cases  of  amputation  of  the  thigh  at  Saint  Maurice  22 
were  for  wounds  of  the  knee.  Turner  thinks  many  of  these  limbs 
could  have  been  saved  by  resection  at  the  knee-joint.  The  con- 
dition of  a  patient  with  an  amputation  of  the  thigh  is  incompar- 
ably worse  than  that  of  one  with  resection  at  the  knee;  moreover, 
the  mortality  in  amputation  at  the  thigh  is  very  high.  Some- 
times these  injuries  of  the  knee  recover  with  ankylosis  after  long 
treatment,  but  in  some  cases  general  septicemia  develops  and 
amputation  becomes  necessary.  In  the  great  majority  of  cases 
resection  is  sufficient.  He  cites  four  cases  in  his  own  practice. 
The  case  histories  are  given  showing  that  they  were  very  severe 
cases. 


ABSTRACTS  OF  WAR  SURGERY  297 

TREATMENT    OF    GUNSHOT  WOUNDS    OF    THE    KNEE- 
JOINT.— H.  M.  W.  Gray.     Brit.  Med.  Jour.,  1915,  ii,  p.  41. 

The  author  reports  that  in  the  earlier  part  of  the  present  war 
the  result  of  treatment  in  gunshot  wounds  of  the  knee  among 
those  who  recovered  was  marked  by  ankylosis  in  the  majority  of 
cases.  The  period  of  convalescence  was  usually  most  painful  and 
precarious.  These  results  are  attributed  to  erroneous  ideas  of 
treatment  which  have  been  abandoned.  Among  the  errors  men- 
tioned are  :  (1)  the  belief  that  suppurative  infection  of  the  joint 
demanded  free  and  prolonged  drainage ;  (2)  the  use  of  drainage 
tubes,  more  or  less  large  in  size,  inserted  deeply  into  the  various 
recesses  of  the  joint;  and  (3)  the  use  of  strong  antiseptic  treat- 
ment which  was  inimical  to  a  restitutio  ad  integrum,  because  the 
deleterious  action  of  the  antiseptics  destroyed  the  synovial  mem- 
brane and  cartilage,  forming  a  fruitful  source  of  ankylosis. 

In  lieu  of  the  foregoing  line  of  treatment  the  following  factors 
are  now  insisted  upon:  (1)  wounds  of  the  joint  that  are  apt 
to  become  septic  demand  mobilization;  but  few  such  cases  when 
received  from  the  front  are  provided  with  properly  applied 
splints.  This  important  lapse  in  treatment  is  apt  to  favor  the 
entrance  of  sepsis  to  a  knee  previously  infected,  and  again  there 
is  danger  that  it  might  stimulate  a  virulent,  diffuse  inflamma- 
tion instead  of  a  mild,  localized  one.  It  is  insisted  upon  that  dur- 
ing the  treatment  the  splint  be  retained  two  or  three  weeks  at 
least.  Later,  gentle  passive  movement  is  recommended;  (2)  for- 
merly, foreign  bodies  were  removed  ' '  only  if  they  led  to  trouble ' ' ; 
now  only  those  embedded  in  bone  outside  the  joint  are  left  un- 
disturbed, all  others  are  removed  whether  they  are  the  source  of 
immediate  trouble  or  not;  (3)  excision  of  the  wound  in  the  skin 
and  superficial  tissues  is  now  a  routine  process. 

The  present  treatment  is  summarized  as  follows:  Excise 
wounds  of  the  skin  and  superficial  soiled  or  necrotic  muscle  and 
fascia.  Enlarge  the  wound  freely  if  necessary.  Remove  foreign 
bodies,  previously  localized  by  x-rays,  after  possible  enlargement 
of  the  synovial  membrane.  Flush  the  synovial  cavity  with  5 
per  cent  saline  solution.  In  very  acute  cases  make  fresh  in- 
cisions. Trim  the  edges  of  the  wound  in  the  synovial  membrane ; 
suture  if  the  sepsis  is  not  acute.  Insert  drainage  tube  down  to 
but  not  through  the  wound  in  synovial  membrane.  Fill  the  rest 
of  the  wound  firmly  with  "tablet  and  gauze"  dressing.  Inject 
formalin,  glycerine,  or  ether,  through  the  fresh  puncture.    Clean 


298  ABSTRACTS  OF  WAR  SURGERY 

and  redisinfect  the  surrounding  skin.  Apply  superficial  dress- 
ings and  light  bandage.  Immobilize  in  suitable  splint.  If  this 
fails  free  arthrotomy  and  possibly  amputation  should  be  em- 
ployed. 

In  looking  over  the  36  cases  detailed  briefly  for  the  most  part, 
the  reviewer  finds  that  27  were  due  to  shrapnel  or  shell  frag- 
ment, and  9  resulted  from  bullets  or  missiles  the  nature  of  which 
is  not  specified.  To  have  cured  28  of  these  with  movable  joints 
is  an  achievement  that  is  heartily  commended,  considering  the 
nature  of  the  missiles  causing  the  wounds. 

The  author  insists  on  immobilization  as  a  prime  factor  in  all 
knee-joint  wounds.  The  treatment  is  not  new  since  it  is  an  es- 
tablished mode  of  treatment  in  surgery  as  a  rule,  and  military 
surgery  in  particular.  We  have  taught  the  value  of  immobiliza- 
tion for  years,  not  only  in  joint  injuries  and  fractures  from  gun- 
shot, but  in  all  gunshot  wounds  including  those  of  soft  parts  even 
where  immobilization  is  impossible.  Fixation  of  wounded  parts 
plays  a  great  role  as  a  prophylactic  against  the  development  of  in- 
fection. When  enforced  transportation  is  necessary,  as  often  hap- 
pens in  military  practice,  it  adds  to  the  comfort  of  the  patient  in 
keeping  down  pain,  it  prevents  the  recurrence  of  hemorrhage,  and 
it  also  favors  early  healing. 

The  only  thing  recommended  by  the  author  that  savors  of 
new  treatment  is  excision  of  the  wound  of  the  skin  and  super- 
ficial soiled  or  necrotic  muscle  and  fascia,  and  this  is  only  new 
as  it  may  apply  to  the  channel  of  a  bullet  wound  and  not  to 
shell  wounds  or  gunshot  wounds  which  exhibit  the  characteristics 
of  explosive  effects.  Here  we  have  a  great  deal  of  devitalized 
tissue  and  the  rule  of  treatment  is  the  same  as  that  practiced  in 
all  wounds  with  coagulation  necrosis;  i.  e.,  the  removal  of  con- 
tused parts.  The  rest  of  the  so-called  new  treatment  which 
refers  to  free  drainage,  removal  of  foreign  bodies  in  the  joint 
after  localization  by  x-rays,  flushing  the  synovial  cavity  with 
saline  solution,  insertion  of  drainage  tubes  to  and  not  into  the 
synovial  cavity,  etc.,  is  sound  practice. 

RESECTION  OF  THE  SHOULDER  IN  WAR  SURGERY.— 

Fourmestraux.    Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1916,  xlii, 
p.  1677. 

Among  1,300  ambulance  patients  Fourmestraux  found  41 
shoulder  injuries  with  isolated  or  simultaneous  lesions  of  the  hu- 


ABSTRACTS  OF  WAR  SURGERY  299 

meral  head  of  the  scapula  and  of  the  clavicle;  in  11  of  these  re- 
section was  necessary. 

In  these  11  cases  of  resection  of  the  shoulder  Fourmestraux 
made  a  vertical  incision  starting  from  the  acromioclavicular 
articulation.  This  incision  was  continued  behind  and  below  on 
the  spine  of  the  scapula.  The  acromioclavicular  articulation  was 
bared ;  the  acromion  temporarily  detached ;  the  capsule  opened ; 
the  humeral  extremity  more  or  less  resected,  the  circumflex 
nerve  having  been  pulled  down  out  of  the  way  for  protection. 

This  incision  allows  a  good  exploration  of  the  scapula  and  the 
removal  of  crushed  parts  of  the  superoexternal  angle,  an  injury 
which  is  often  a  concomitant.    It  allows  good  drainage  also. 

The  end-results  can  not  be  stated  by  the  author  at  the  present 
time  but  he  hopes  to  report  later. 

PRIMARY  RESECTION  IN  THE  TREATMENT  OF  ARTICU- 
LAR GUNSHOT  WOUNDS  V/ITH  FRACTURE.— G.  Cotte. 
Rev.  de  chir.,  1916,  li,  p.  383. 

Cotte  shows  the  results  obtained  for  each  joint  in  the  treat- 
ment of  articular  injuries  with  fracture  by  means  of  resection. 
From  this  study  he  deduces  the  conditions  in  which  resection 
should  be  employed,  in  which  cases  it  should  be  reserved,  and  at 
what  time  it  should  be  practiced. 

A  general  study  of  articular  wounds,  such  as  are  observed  at 
the  front,  shows  that  these  are  of  three  types.  The  first  com- 
prises those  which  fall  into  the  abstention  class.  These  comprise 
bullet  wounds  with  punctiform  orifices.  In  these  the  lesions  al- 
most always  heal  in  an  aseptic  manner  providing  no  hasty  maneu- 
vers are  used.  The  treatment  should  be  rigorous  immobilization 
of  the  injured  joint  in  a  plaster  jacket,  and  not  the  least  injection 
should  be  made  into  the  trajectory  under  pretext  of  disinfecting 
it.  Of  78  articular  wounds  with  fractures  treated  by  Cotte,  16 
were  of  this  class,  and  abstention  has  always  given  good  results. 

Although  the  end-results  are  generally  good,  yet  in  certain 
cases  such  as  those  in  which  a  wedging  of  the  articular  surface, 
difficult  to  reduce,  exists,  a  prudent  and  experienced  surgeon  will 
intervene  after  some  days  to  effect  reduction  of  the  fracture,  etc. 
It  suffices  to  say  that  the  aseptic  evolution  of  the  wound  is  com- 
patable  with  all  operative  measures. 

The  second  type  comprises  those  injuries  which  call  for  early 
amputation.    Such  are  ruptured  and  crushed  joints  in  which  the 


300  ABSTRACTS  OF  WAR  SURGERY 

soft  parts  are  so  badly  damaged  that  a  conservative  operation 
can  scarcely  be  thought  of,  with  vascular  concomitant  lesions  and 
the  consequent  expectant  development  of  grave  infection.  More- 
over, this  class  includes  those  cases  in  which  the  patient's  gen- 
eral state  is  too  feeble  to  permit  a  much  longer  conservative 
intervention. 

Of  the  78  articular  wounds  treated  14  were  of  this  type.  Of 
these  amputations  8  were  due  to  the  primary  condition.  In  the 
other  6  an  early  and  better  treatment  would  have  avoided  it. 

Aside  from  these  two  types  the  author  is  of  the  opinion  that  all 
other  articular  wounds  call  for  resection.  This  experience  at  the 
front  has  convinced  him  that  the  simpler  procedures  of  widely 
opening  up  the  wound  and  clearing  it  out  do  not  suffice.  Resec- 
tion does  all  that  these  operations  do  and  does  it  better  and  the  end 
results  are  much  more  satisfactory.  The  clear  and  regular  sur- 
faces due  to  resection  are  better  than  the  irregular  surfaces  left  in 
a  ripping  up  of  the  wound.  Again  the  facts  justify  it.  Of  the 
45  cases  treated  by  resection,  only  2  have  died.  The  facts  in  these 
2  cases  (alcoholism  and  embolism)  show  that  a  more  conservative 
treatment  would  not  have  averted  these  results. 

As  regards  end-results  there  can  be  no  doubt  but  that  after 
resection  the  wounded  recover  much  more  simply  and  rapidly  than 
after  clearing  operations.  Regarding  the  orthopedic  results  of  re- 
section the  small  number  of  cases  operated  upon  by  Cotte  is  not 
sufficient  to  authorize  him  to  affirm  the  superiority  of  resection 
over  conservative  procedures.  While  a  priori  it  must  be  admitted 
that  many  resected  joints  will  not  recover  their  mobility,  or  the 
limb  may  recover  with  imperfect  functioning,  yet  a  limb  only 
partly  useful  is  better  than  no  limb,  and  it  can  be  said  that  resec- 
tion will  almost  certainly  obviate  infection  or  check  the  results 
of  it. 

Regarding  the  time  of  intervention  and  the  method,  resection 
should  be  as  early  as  possible,  as  it  is  impossible  to  say  what  will 
be  the  evolution  of  an  articular  injury  after  its  occurrence.  The 
author  has  recourse  to  the  subperiosteal  method  following  the 
general  rules  of  resection  laid  down  by  Oilier.  The  anatomic  route 
is  selected  which  allows  the  largest  exposure  of  the  articulation 
while  avoiding  the  nerves,  muscles  and  tendons.  With  these  limi- 
tations, the  resection  will  be  as  economic  as  possible. 

Cotte  gives  the  clinical  details  of  several  cases  of  different  artic- 
ular lesions  treated  by  resections  to  illustrate  his  contentions. 


ABSTRACTS  OF  WAR  SURGERY  301 

TREATMENT  OF  TRAUMATIC  ARTHRITIS  OF  THE  KNEE. 

— Marchak  and  Dupont.    Bull,  et  mem.  Soc.  de  chir.  de  Paris, 
1916,  xlii,  p.  1387. 

The  memoirs  of  these  two  authors  were  reported  on  by  Del- 
bet,  who  pointed  out  that  they  were  totally  at  variance  with 
each  other.  Marchak  sustains  four  points:  (1)  the  necessity  for 
early  arthrotomy;  (2)  for  large  arthrotomies  to  follow  Delbet's 
technic;  (3)  the  utility  of  extension  after  arthrotomy;  (4)  the 
inconvenience  of  systematic  resections.  Dupont  abstains  from 
all  interventions,  immobilizes  the  limb  and  packs  it  in  ice.  He 
was  led  to  adopt  this  technic  by  the  bad  results  from  arthroto- 
my. 

Marchak  cared  for  15  cases  of  purulent  arthritis  of  the  knee. 
Of  these  1  died  from  tetanus,  and  1  from  repeated  hemorrhages. 
In  4  cases  amputation  was  necessary.  There  were  9  recoveries 
with  ankylosis.  Besides  these  15  cases  he  had  3  other  cases  in 
which  early  arthrotomy  was  done  at  the  field  hospital.  In  these 
3  cases  evolution  was  simple  and  they  are  now  without  compli- 
cation. Marchak  therefore  concludes  that  the  knee  must  be 
opened  on  the  least  showing  of  articular  reaction. 

Dupont  treated  7  patients  with  immobilization  and  ice  pack. 
One  died  on  the  fifteenth  day  from  purulent  arthritis,  arthroto- 
my followed  later  by  amputation  having  been  tried  in  vain. 
The  other  6  cases  recovered.  All  these  were  severe  cases  and 
in  5  of  them  a  projectile  was  lodged  in  the  articular  cavity.  In 
2  cases  these  were  not  extracted  and  in  the  others  the  extrac- 
tion was  only  made  secondarily  when  the  articular  reaction  had 
completely  disappeared. 

In  discussing  these  contrary  reports  Delbet  states  that  the  end 
sought  in  making  a  large  opening  of  the  knee  is  not  the  removal 
of  a  foreign  body  but  the  avoidance  of  infection.  Infection  is 
not  constant,  and  its  frequency  can  not  be  stated  with  precision, 
but  its  presence  may  be  detected  by  making  a  pyoculture.  The 
result  of  this  will  absolutely  set  at  rest  all  questions  as  to  ab- 
stention or  intervention.  This  will  not  take  more  than  three 
to  five  minutes.  If  microbes  are  found  then  a  simple  arthrotomy 
is  made.  If  not,  the  limb  is  immobilized  and  examination  again 
made  the  next  day.  If  streptococci  are  abundant  in  the  pus 
wide  arthrotomy  will  be  done.  If  there  is  a  foreign  body  in 
the  articulation  it  is  preferable  to  remove  it  at  once,  but  the 


302  ABSTRACTS  OF  WAR  SURGERY 

question  of  suturing,  draining,  or  leaving  the  wound  open  de- 
pends as  before  on  what  is  found  in  the  pyoculture.  Osseous 
lesions  in  themselves  do  not  afford  any  special  indications.  In- 
fection and  the  patient's  resistance  must  be  the  guide. 

Delbet's  personal  experience  in  treating  knee  injuries  accord- 
ing to  this  procedure  is  not  large.  Of  17  cases,  4  were  aseptic 
and  cured  without  arthrotomy.  In  3,  simple  arthrotomy  was 
done,  the  pyoculture  being  weakly  positive.  The  3  recovered 
but  one  was  ankylosed.  In  the  other  10  cases  the  pyoculture 
was  strongly  positive,  and  all  had  osseous  lesions.  In  all  these, 
wide  arthrotomies  were  made  with  immobilization  and  exten- 
sion. In  1  case  a  resection  was  done.  Five  of  these  patients 
recovered  without  ankylosis ;  in  4  it  was  necessary  to  amputate. 
In  3  of  these  amputation  cases  the  course  was  adopted  be- 
cause while  the  patient's  resistance  was  declining,  the  successive 
pyoculture  showed  increase  in  the  number  of  microbes.  All  the 
patients  recovered.  Pyoculture,  therefore,  while  it  indicates  ab- 
stention in  a  certain  number  of  cases,  suggests  intervention 
when  necessary  in  infected  cases,  and  limits  it  to  the  resistance 
of  the  patient  with  a  simple  dressing,  until  further  treatment 
can  be  given  in  a  general  hospital,  provided  there  is  no  evidence 
of  infection. 

In  comminuted  fractures,  the  authors  state  with  positiveness 
that  however  freely  the  wound  is  opened  up,  the  bone  fragments 
must  be  left  in  situ.  There  are  only  two  exceptions  to  this  rule 
of  not  removing  bone  fragments:  (1)  when  the  articular  end 
of  a  bone  is  shattered,  all  loose  bone  should  be  removed  from 
the  joint;  and  (2)  if  a  bit  of  bone  is  clearly  devoid  of  all  vas- 
cular connection  and  lies  in  a  septic  wound,  it  should  be  taken 
out. 

Operative  fixation  of  fragments  is  not  recommended.  If 
much  communition  is  present,  plating  or  wiring  is  useless  and 
a  mechanical  impossibility,  and  when  the  fracture  is  not  com- 
minuted, it  should  be  treated  by  extension.  Boring  bone  for 
plating  invariably  leads  to  necrosis  when  the  wound  is  already 
infected. 

A  very  good  description  is  given  of  the  latest  and  best  ap- 
paratus made  of  wire,  which  is  easily  transported  in  the  field, 
as  well  as  a  careful  description  of  the  technic  in  the  practice  of 
immobilization. 


ABSTRACTS  OP  WAR  SURGERY  303 

COMMUNICATION  FROM  U.  S.  ARMY  BASE  HOSPITAL  NO. 

5. — R.  B.   Osgood.     Am.  Jour.  Orthop.  Surg.,  1917,  xv,  p. 
668. 

If  a  foreign,  body  has  perforated  a  joint  and  its  tract  appears 
to  be  reasonably  clean,  the  joint  is  immobilized  and  carefully 
watched  even  in  the  presence  of  increased  surface  heat  and  a 
tight  synovitis.  At  most,  an  aspiration  is  done,  and  the  nature 
of  the  fluid  and  its  bacteriology  determined.  Many  of  these 
cases  quiet  down  in  a  surprisingly  satisfactory  manner. 

In  the  case  of  a  penetrating  wound  with  the  foreign  body  still 
present,  actually  in  the  joint  or  in  the  tissues  involved  in  its 
mechanism,  action  is  dictated  by  several  considerations — the 
size  and  location  of  the  foreign  body,  the  reaction  of  the  joint, 
the  possibility  that  a  part  of  the  active  joint  symptoms  have 
been  caused  by  the  inevitable  trauma  of  transportation  and  bj- 
the  temperature  and  general  condition  of  the  individual. 

In  general,  it  may  be  said  that  foreign  bodies  of  any  size, 
within  a  joint  cavity  proper  or  embedded  in  the  articular  ends 
of  the  bones  near  the  cartilage  line,  should  be  removed  at  some 
time.  It  is  often  wise  to  allow  the  first  traumatic  reaction  to 
subside  before  opening  the  joint.  Under  rest  and  complete  fixa- 
tion, they  frequently  quiet  down  quickly  and  may  then  be 
opened  more  safely.  If  operation  is  undertaken,  the  external 
wound  is  excised,  the  joint  opened,  and  after  the  foreign  body 
has  been  found  and  removed,  the  joint  is  washed  out  for  at 
least  ten  minutes  with  a  weak  bichloride  or  sterile  normal  saline 
or  perhaps  even  the  antiseptic  solution  devised  by  Dakin.  The 
form  most  commonly  used  is  the  so-called  eusol  in  strength  of 
1 :200  or  1 :400.  After  thorough  irrigation  by  means  of  a  soft 
catheter  tube  inserted  into  the  deepest  recesses  of  the  joint, 
the  joint  cavity  is  tightly  closed  with  fine  chromic  catgut,  and 
the  external  wound  only  partially  sutured,  or  not  at  all,  de- 
pending upon  the  severity  of  the  infection  and  the  tissue  drain- 
age. 

A  small  drain  of  rubber  tissue  is  left  in,  extending  down  to 
but  not  through  the  capsule.  Many  of  the  surgeons,  especially 
at  the  casualty  clearing  station,  are  using,  in  addition,  a  sub- 
stance known  as  "bipp"  (bismuth-iodoform-paraffine)  in  thick 
liquid  or  soft  paste  consistencies,  leaving  a  small  amount  in  the 
joint  and  wiping  it  over  the  external  wounds  and  incised  tis- 
sues. It  is  the  antiseptic  treatment  returning.  An  article  by 
Morison  gives  a  full  description  of  the  method  which  its  origi- 


304  ABSTRACTS  OF  WAR  SURGERY 

nator  considers  the  best.  The  author  and  his  colleagues  have 
had  certain  cases  of  iodoform  and  bismuth  poisoning  follow- 
ing its  use,  the  former  shown  by  mental  disturbances  and  per- 
haps vomiting,  also  later  by  a  dark  line  at  the  margin  of  the 
gums  and  sometimes  by  real  stomatitis.  There  seems  to  be  a 
marked  individual  idiosyncrasy  and  susceptibility,  but  it  is  cer- 
tainly often  followed  by  these  effects. 

The  compound  fractures  complicated  as  they  all  are  by  sepsis, 
call  for  the  most  efficient  methods  of  fixation,  which  must  at 
the  same  time  provide  adequate  room  for  copious  dressings  and 
treatment  by  the  Carrel  technic.  At  the  primary  operation, 
when  adequate  drainage  is  provided  and  the  tissues  damaged 
beyond  repair  are  removed,  it  has  been  proved  to  be  an  axiom 
never  to  remove  even  seemingly  completely  separated  fragments 
of  bone.  The  early  or  even  late  excisions  of  joints  and  the 
clean  removal  of  bone  fragments  have  not  resulted  in  a  quick 
subsidence  of  sepsis,  nor  has  joint  function  or  union  of  bony 
ends  been  favored.  The  results  of  these  procedures  are  often 
deplorable. 

Plaster-of-Paris  dressings  with  wide  openings  bridged  by 
loops  of  metal  or  plaster  offer  the  most  perfect  fixation  and 
greatest  comfort  to  the  patient.  These  are  employed  in  spe- 
cially difficult  and  painful  cases.  Their  disadvantages  in  an  Eng- 
lish general  evacuating  hospital,  where  there  are  often  periods 
of  great  rush,  are  their  time-consuming  initial  application  and 
the  practical  certainty  that  they  will  be  removed  when  they 
reach  the  home  hospital.  Thomas  and  Jones  splints  are  admir- 
ably adaptable,  easy  to  make,  capable  of  quick  application,  can 
be  supplied  in  large  quantities  to  the  front  stations,  and  al- 
low of  comfortable  transportation.  They  leave  little  to  be  de- 
sired. They  have  adopted  combinations  of  these  splints  by 
which  arms  may  be  fixed  in  abduction  and  the  patient  made 
ambulatory. 

THE  IMMEDIATE  RESULTS  OF  SURGICAL  INTERVEN- 
TION IN  111  OASES  OF  PURULENT  ARTHRITIS  OF 
THE  LARGE  ARTICULATIONS.— Auvray.  Bull,  et  mem. 
Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  683. 

All  of  the  111  cases  observed  by  Auvray  were  clearly  purulent. 
They  occurred  in  the  rear  hospitals  several  days  and  even  weeks 
after  injury,  and  the  arthritis  had  been  overlooked. 

Only  the  immediate  results  of  intervention  are  reported  as 


ABSTRACTS  OF  WAR  SURGERY  305 

the  majority  of  the  patients  could  not  be  followed  up.  The 
111  cases  comprised:  34  purulent  arthritis  of  the  knee,  32  puru- 
lent arthritis  of  the  elbow,  20  purulent  arthritis  of  the  shoulder, 
12  purulent  arthritis  of  the  ankle,  7  purulent  arthritis  of  the 
wrist,  4  purulent  arthritis  of  the  hip,  2  purulent  arthritis  of 
the  sacro-iliac  joint. 

Of  the  series  8  patients  died,  total  mortality,  7.2  per  cent; 
12  were  amputated,  all  being  of  the  lower  limb.  All  the  shoulder 
cases  have  had  to  be  resected. 

Auvray  says  that  the  results  show  very  clearly  the  great 
gravity  of  purulent  arthritis  of  the  lower  limb,  there  being  12 
amputations  and  6  deaths;  especially  the  knee-joint  lesion 
which  is  incontestably  the  most  severe.  Also  he  points  out 
how  powerless  an  arthrotomy  is  in  stopping  the  evolution  of 
infected  joint  complications. 

After  several  such  drainage  operations  resection  has  had  to 
be  resorted  to,  resulting  in  the  cure  of  the  patient.  In  many 
of  the  cases  the  bad  results  are  due  to  faulty  and  insufficient 
arthrotomy  methods  and  other  causes;  but  Auvray 's  experience 
leads  him  to  think  unfavorably  of  simple  drainage  operations, 
as  resection  in  his  experience  has  saved  many  lives  and  limb?:. 

He  points  out  the  necessity  for  early  diagnosis  and  treat- 
ment at  the  surgical  stations  at  the  front.  On  the  preliminary 
dressings,  especially  in  the  case  of  purulent  arthritis  of  the 
knee,  often  depends  the  future  of  the  limb,  and  even  the  life 
of  the  patient. 

ARTHROTOMY  FOLLOWED  BY  IMMEDIATE  CLOSURE  OF 
THE  ARTICULATION  IN  THE  TREATMENT  OF  CER- 
TAIN WOUNDS  OF  THE  KNEE.-^-H.  Gaudier  and  R. 
Montaz.    Lyon  chir.,  1917,  xiv,  p.  77. 

The  immediate  suture  of  the  synovial  membrane  after  arthrot- 
omy in  knee-joint  wounds  requires  the  following  conditions:  (1) 
prompt  surgical  intervention;  (2)  complete  excision  of  all  injured 
tissues  after  extraction  of  foreign  bodies;  (3)  very  careful  hemo- 
stasis ;  (4)  the  possibility  of  supervision  of  the  patient  during  the 
first  few  days;  (5)  thorough  immobilization. 

In  a  series  of  fifteen  cases  reported  by  the  author  the  aver- 
age time  elapsing  between  injury  and  operation  was  from  six 
to  ten  hours.  In  some  cases  it  ran  from  twenty-four  to  seventy- 
two  hours.  Satisfactory  results  were  obtained  in  all  except 
one  case  which  became  transformed  into  septic  arthritis.    Such 


306  ABSTRACTS  OF  WAR  SURGERY 

good  results  are  to  be  explained  by  the  long  period  that  artic- 
ular fluid  may  remain  sterile  in  spite  of  existing  infection  of 
the  surrounding  tissues  and  the  presence  of  the  bacillus  per- 
fringens  on  the  projectiles,  which  fact  is  known  from  the  re- 
searches of  Feissinger. 

The  indications  after  x-ray  examinations  are : 

1.  Surgical  cleansing  of  all  soft  parts;  excision  of  wound 
edges  and  injured  tissues;  thorough  hemostasis. 

2.  Wide  parapatellar  arthrotomy,  saving  the  quadriceps  ten- 
don if  possible. 

3.  Very  careful  cleansing  of  bone  injuries;  extraction  of  the 
projectile  by  curette  if  in  the  bone;  scraping  the  whole  frac- 
ture area  and  smoothing  of  bone  edges. 

4.  Lavage  of  the  articular  cavity  by  hexamethylene  or  ether. 

5.  Suture  of  the  synovial  membrane  by  isolating,  if  possible, 
the  bone  injury  from  the  main  cavity  of  the  joint.  A  small 
plug  of  gauze  is  left  in  the  bone  cavity  and  removed  after 
twenty-four  hours.  In  suitable  cases  there  should  be  suture  of 
the  soft  parts  above  the  closed  synovial  membrane,  followed 
by  immobilization  of  the  limb. 

The  evolution  is  nearly  always  simple;  but  there  may  be  a 
slight  rise  of  temperature  during  the  first  days.  After  two 
weeks  when  all  inflammatory  reaction  has  vanished,  mobiliza- 
tion may  be  begun. 

Contraindications  are :  clinical  signs  of  infection ;  great  de- 
struction of  soft  parts  rendering  suture  impossible;  serious 
bone  injuries  calling  for  primary  resection. 

In  the  author's  15  cases,  14  recovered  with  a  movable  joint; 
1  recovered  with  ankylosis. 

TREATMENT  OF  GUNSHOT  WOUNDS  OF  KNEE-JOINT.— 

H.  M.  W.   Gray.     Jour.  Am.  Med.  Assn.,  Oct.  6,   1917,  p. 
1202. 

In  dealing  with  operative  cases  Gray  believes  that  if  the  in- 
jury has  implicated  the  main  vessels  so  that  the  foot  is  already 
cold  and  dead,  amputation  should  be  done  just  above  the  knee 
if  the  wound  is  likely  to  remain  fairly  clean,  and  through  the 
knee  if  sepsis  is  present  and  the  condyles  are  undamaged.  In 
the  latter  class  of  cases  reamputation  is  frequently  necessary, 
and  when  the  condyles  are  left  it  can  be  done  so  as  to  provide 
the  longest  possible  thigh  stump.  If,  as  sometimes  happens, 
one  or  other  popliteal  nerve  is  shot  away  so  extensively  that  it 


ABSTRACTS  OF  WAR  SURGERY  307 

can  not  be  sutured  later  on,  and  if  the  bones  are  much  soiled 
as  well  as  comminuted,  the  probability  is  that  primary  ampu- 
tation is  the  best  course.  If  sepsis  is  well  established  in  pres- 
ence of  much  comminution,  especially  if  there  be  gas  gangrene, 
and  the  patient  in  low  condition  from  hemorrhage  or  toxic  ab- 
sorption, amputation  must  be  done.  If,  in  less  severe  cases, 
the  opposing  ends  of  the  long  bones  are  so  comminuted  that 
smooth  articular  surfaces  are  not  available,  it  is  probably  best 
to  do  primary  resection  in  the  way  recommended  by  Fuller- 
ton.  If  large  fragments  have  resulted  from  the  injury,  if  the 
patient  has  been  received  early  and  is  in  good  condition,  and 
if  one  is  fairly  sure  of  getting  away  infective  material,  the 
patient  should  be  given  a  chance.  As  a  general  rule,  if  the 
patella  alone  has  been  shattered,  as  happens  fairly  frequently, 
the  fragments  should  be  removed. 

If  possible,  the  synovial  cavity  should  be  closed,  except  for 
a  small  drainage  opening,  by  suturing  the  lateral  edges  and 
aponeuroses,  possibly  after  undercutting  the  synovial  mem- 
brane on  each  side,  or  by  loosening  the  suprapatellar  pouch  as 
already  described.  If  this  can  not  be  done,  a  "salt  pack"  should 
be  used.  The  same  procedure  should  be  carried  out  if  con- 
comitant injury  to  other  bones  is  not  extensive.  In  consider- 
ing the  question  of  amputation,  these  points  are  of  great  im- 
portance :  the  possibility  of  removing  or  neutralizing  infective 
material  successfully,  the  amount  and  kind  of  comminution,  the 
concomitant  injury  to  vessels  or  nerves,  and  the  condition  of 
the  patient.  When  conservative  measures  are  decided  on,  the 
following  are  the  most  important  operative  details:  determina- 
tion of  the  track  which  leads  to  the  depth;  thorough  disinfec- 
tion of  skin  and  track;  careful  and  complete  excision  of  exter- 
nal wound  and  track,  including  the  edges  of  the  wound  in  the 
synovial  membrane,  if  possible  in  one  piece.  Pockets  must  not 
be  cut  into.  The  least  little  bit  of  infected  tissue  left  behind 
may  prevent  success ;  provision  of  ample  access  to  foreign 
bodies  or  comminuted  surfaces  in  the  joint. 

Careful  removal,  under  direct  vision,  whenever  feasible,  of 
all  foreign  material,  whether  free  in  the  joint  or  embedded  in 
the  articular  surfaces.  Closure  of  the  wound  in  layers,  using 
fine  catgut  for  the  synovial  membrane.  Drainage  tubing  should 
not  project  into  the  joint.  If  the  wound  in  the  synovial  mem- 
brane can  not  be  closed,  a  small  "salt  pack,"  separate  from 
any  other  which  may  be  required  for  the  rest  of  the  wound, 
should  be  inserted  firmly  "down  to  but  not  into"  the  joint,  and 


308  ABSTRACTS  OP  WAR  SURGERY 

should  be  left  until  it  is  absolutely  loose.  Tendinous  or  liga- 
mentous structures  exposed  during  operation  should  be  covered 
by  skin  and  subcutaneous  tissue;  otherwise  they  are  very  apt 
to  slough,  and  this  postpones  closure  of  the  wound,  and  there- 
fore prolongs  convalescence.  If  there  is  much  effusion  into  or 
from  the  joint,  of  whatever  nature,  or  if  raw  surfaces,  whether 
of  bone  or  soft  tissue,  are  left  in  the  joint,  at  the  end  of  opera- 
tion, a  tube  should  always  be  inserted  "down  to  but  not  into" 
the  synovial  cavity.  The  injection  of  ether,  formaldehyd  solu- 
tion, glycerin,  or  hypertonic  (5  per  cent)  saline  solution  into 
closed  joints,  is  of  doubtful  value.     They  are  all  irritants. 

In  dealing  with  wounds  of  the  knee-joint  Page  urges  that 
the  natural  defensive  powers  of  the  part  against  infection 
should  be  borne  in  mind.  Primary  prophylactic  (that  is, 
within  twenty-four  hours  of  injury)  operations  should  be  rad- 
ical, and  secondary  operations  undertaken  on  account  of  pro- 
gressing infection,  should  be  planned,  short  of  amputation,  on 
conservative  lines.  The  expectant  treatment  of  wounds  of  the 
knee-joint  is  only  justifiable  in  the  case  of  typical  perforating 
injuries  due  to  a  rifle  bullet.  All  wounds  of  the  joint  caused 
by  shell  fragments  or  distorted  bullets  should  be  considered  as 
primarily  infected.  The  primary  prophylactic  treatment 
should  consist  in  the  removal  of  any  foreign  bodies  present  and 
in  the  excision  of  the  whole  wound  track  at  the  earliest  pos- 
sible time  after  injury.  The  results  at  present  are  particularly 
bad  in  cases  in  which  gross  comminution  of  the  diaphyses  is 
present.  A  primary  excision  or  erasion  of  the  joint  (within 
twenty-four  hours)  would  probably  improve  the  results  in  such 
instances  by  preventing  the  development  of  osteomyelitis.  Re- 
peated aspiration  of  the  joint  and  the  intra-articular  injection 
of  any  of  the  antiseptics  in  common  use  are  calculated  to  prej- 
udice the  natural  defense.  It  is  safest  to  leave  for  a  few  days 
some  drainage  along  the  wound  track  after  operation,  certainly 
when  bone  injury  is  present.  Any  infection  then  left  may  be- 
come localized  in  the  same  way  as  occurs  in  the  case  of  the 
peritoneum.  A  gauze  wick  makes  a  satisfactory  form  of  drain. 
Immobilization  of  the  joint  during  all  critical  periods  is  es- 
sential. An  interrupted  plaster-of-Paris  splint  affords  the  best 
means  of  effecting  this.  When  general  infection  of  the  joint 
has  taken  place  treatment  by  fixation,  lateral  arthrotomy  and 
immunization  gives  the  best  chance  of  saving  the  limb.     Sec- 


ABSTRACTS  OF  WAR  SURGERY  309 

ondary  abscesses  are  to  be  expected,  and  should  be  evacuated 
after  their  complete  development.  Neither  cross-section  and 
flexion  of  the  joint  nor  secondary  excision  of  the  knee  are  sound 
procedures. 

TREATMENT  OF  WOUNDED  KNEE-JOINT.— II.  G.  Barling. 
Brit.  Med.  Jour.,  Sept.  1,  1917,  p.  277. 

Barling  analyzes  845  cases.  In  a  very  high  proportion  of 
cases  excision  of  the  wound,  removal  of  bone  when  necessary, 
removal  of  any  retained  foreign  body,  irrigation  of  the  joint 
and  closure  by  suture  has  been  followed  by  a  perfectly  satis- 
factory healing  without  further  interference.  The  proportion 
of  these  cases  requiring  further  intervention  is  25.5  per  cent, 
and  Barling  believes  that  free  use  of  the  joint  is  likely  to  re- 
sult in  a  large  majority  of  those  in  whom,  the  primary  opera- 
tion was  successful.  In  the  group  in  which  complete  closure 
was  not  possible  or  was  deemed  inadvisable,  and  in  which  the 
wound  was  packed,  the  results  are  not  so  good.  This  group 
includes  the  worst  cases  of  injury  to  the  bones  entering  the 
knee-joint.  Here  the  proportion  of  cases  in  which  further 
operative  interference  was  required  is  38.4  per  cent.  Very  use- 
ful joint  function  may  result  in  many  cases.  Excision  of  the 
wound,  removal  of  bone  when  required,  removal  of  foreign 
body,  suture  of  the  wound,  if  possible,  and  packing  as  an  alter- 
native in  selected  cases,  is  the  program  Barling  recommends. 
In  a  considerable  number  of  instances  materials  such  as  for- 
maldehyd  solution  and  glycerin  or  ether  have  been  injected 
and  retained  in  the  joint  cavity.  A  few  surgeons  pack  the 
'joint  with  urea,  and  favorable  results  were  obtained.  One 
operator  makes  a  separate  incision  at  some  distance  from  the 
wound  of  entry,  thus  securing  that  at  all  events  he  drives  noth- 
ing septic  into  the  joint. 

Barling  questions  whether  it  matters  much  what  fluid  is  used 
to  wash  out  the  joint,  the  main  advantage  is  the  mechanical 
cleaning  out  of  septic  material,  fibrin  and  blood  clot;  but  this 
should  be  done  thoroughly  through  a  free  opening;  the  use  of 
cannulas  for  this  purpose  is  insufficient.  Barling  deprecates 
aspiration  of  the  joint  and  irrigation  or  injection  with  an  anti- 
septic fluid,  to  which  he  would  resort  only  when  the  fluid  showed 
a  low  corpuscular  element,  a  moderate  polymorphonuclear  count, 


310  ABSTRACTS  OF  WAR  SURGERY 

and  a  sparsity  of  infective  organisms, — conditions  rarely  found. 
Mere  aspiration  is  apt  to  be  followed  by  a  breaking  of  infection 
through  the  capsule  of  the  joint  and  a  spread  into  the  surrounding 
tissues,  a  grave  addition  to  the  patient's  troubles  most  difficult  to 
overcome.  Regarding  aspiration  as  rarely  a  wise  measure,  Barling 
mentions  three  other  courses:  (1)  free  opening  up  of  the  joint; 
(2)  excision  of  the  joint;  and  (3)  amputation. 


FRACTURES 

THE  TREATMENT  OF  GUNSHOT  FRACTURES.— E.  W.  H. 

Groves,   and  T.   H.  Brown.     Lancet,  London,   1916,   cxc,   p. 
900. 

In  a  typical  gunshot  fracture  the  authors  call  attention  to 
three  main  characteristics:  (1)  great  comminution  with  dis- 
placement; (2)  severe  sepsis;  and  (3)  pain  which  becomes  in- 
tolerable with  movement. 

The  indications  are  directed  to  saving  life  and  limb  and  to 
restoring  function.  To  accomplish  these  results,  four  things  are 
necessary:  (1)  immobilization  for  a  long  period;  (2)  free 
drainage  and  frequent  redressings;  (3)  extension  in  a  correct 
line;  (4)  maintenance  of  both  wound  treatment  and  extension 
for  a  period  which  may  be  prolonged  for  several  months.  In 
addition  the  nearby  joint  should  be  semiflexed,  so  that  the 
limb  is  in  physiological  rest;  and  the  flexors  are  relaxed.  Mas- 
sage and  movement  of  the  limb  from  an  early  period  should 
be  practiced. 

Grossly  infected  wounds  are  frequent  after  fracture  by  bombs 
and  shell  fragments,  also  by  military  rifle  bullets  at  proximal 
ranges.  They  should  be  opened  up  freely  at  the  earliest  mo- 
ment. Treatment  should  not  be  delayed  for  x-ray  evidence  if 
it  is  not  at  hand.  Missiles  and  particles  of  clothing  as  well  as 
all  extraneous  matter  should  be  removed.  Small  punctured  and 
penetrating  wounds  should  be  left  alone. 

TREATMENT  OF  SHELL  FRACTURES  OF  THE  FEMUR.— 

E.  Suchanek.    Wien.  klin.  Wchnschr.,  1915,  xxviii,  p.  32. 

At  the  von  Eiselsberg  Clinic  the  treatment  of  shell  fractures 
of  the  femur  is  decidedly  conservative.  In  discussing  the  con- 
dition in  which  the  patients  reach  the  clinic  the  author  reviews 
the  different  methods  employed  for  immobilization  of  the  limb 
at  the  front  and  the  results  obtained  with  the  different  meth- 
ods. In  subcutaneous  fractures  and  in  fractures  with  only 
slight  flesh  wounds  a  plaster  of  Paris  cast  properly  applied  over 
two  long  boards  and  the  limb  sufficiently  padded  serves  admir- 

311 


312  ABSTRACTS  OP  WAR  SURGERY         | 

ably  for  transportation  purposes,  although  the  cast  may  crum- 
ble as  a  result  of  moisture.  He  warns  against  its  use,  how- 
ever, in  cases  with  bad  wounds  or  where  infection  is  suspected, 
as  phlegmons  repeatedly  develop  and  are  overlooked  until  the 
cast  is  removed. 

The  method  is  rather  impracticable  at  the  extreme  front,  as 
the  necessary  boards  and  other  supplies  do  not  reach  the  front 
lines  in  most  instances,  and  the  technic  of  applying  the  cast  is 
not  common  to  all  physicians.  The  Cramer  wire  splint  and  the 
one  modified  by  von  Eiselsberg  have  also  proved  very  satisfac- 
tory for  the  transportation  of  femur  fractures. 

The  treatment  after  arrival  at  the  permanent  hospital  con- 
sists in  extension.  In  cases  of  longitudinal  displacement  this 
treatment  is  supplemented  by  the  Florschutz  method  of  sus- 
pension and  slight  flexion  at  the  knee,  allowing  access  to  the 
injury  without  moving  the  limb  and  without  causing  any  pain. 

If  on  account  of  lateral  displacement  a  reposition  of  the 
fragments  is  not  possible  by  the  single  traction  of  this  method, 
the  Bardenheuer  extension  method  is  employed,  eventually 
supplemented  with  traction  strips  according  to  Euckert,  thus 
exercising  traction  on  the  individual  fragments.  Before  ap- 
plying either  method  x-ray  pictures  are  taken,  and  a  later  pic- 
ture is  taken  before  a  permanent  cast  is  applied.  This  should  not 
be  done  too  early,  as  phlegmons  may  develop  beneath  the  cast 
without  any  appreciable  temperature  elevation  and  may  cause 
considerable  damage  before  they  are  noticed.  After  all  flesh 
wounds  are  healed,  the  danger  of  phlegmon  over,  and  the  frag- 
ments in  good  apposition,  a  cast  may  be  applied,  usually  dur- 
ing the  fourth  week  of  extension. 

The  author  warns  against  the  more  energetic  measures  and 
against  redressment  in  narcosis,  as  well  as  against  the  nail  ex- 
tension method  of  Codivilla-Steinmann.  The  danger  of  spread- 
ing the  infection  in  a  fracture  complicated  by  phlegmon  speaks 
against  the  former,  whereas  the  danger  of  infection  of  the 
drilled  canal  speaks  against  the  later.  The  author  is  well  satis- 
fied with  the  results  obtained  with  the  conservative  method, 
a  good  functional  result  being  striven  for  and  usually  obtained. 

REDUCTION  OF  THE  NUMBER  OF  AMPUTATIONS  AT  THE 
FRONT.= — E.  Marquis.  Bull,  et  mem.  Soc.  de  chir.  de  Paris, 
1915,  xli,  p.  502. 

Marquis  pleads  for  the  most  conservative  treatment  possible 
at  the  front  and  the  reduction  of  the  number  of  amputations 


ABSTRACTS  OF  WAR  SURGERY  313 

to  a  minimum.  He  describes  36  cases  in  which  he  saved  limbs 
where  amputation  would  have  been  considered  necessary  by- 
many  surgeons.  Amputation  was  performed  only  in  16  very 
severe  cases,  with  8  recoveries  and  8  deaths.  Five  patients 
died  without  having  had  amputation  performed,  but  two  of 
these  died  of  tetanus  and  could  not  have  been  saved,  even  by 
immediate  operation ;  two  were  too  severely  injured  to  stand 
amputation,  leaving  only  one  case  in  which  the  failure  to  am- 
putate might  have  been  blamed  for  the  death.  This  was  a 
patient  who  was  apparently  recovering  and  died  suddenly,  evi- 
dently from  embolism. 

The  chief  danger  in  conservative  treatment  is  that  the  best 
moment  for  amputation  may  be  passed  by  in  the  effort  to  save 
the  limb.  In  order  to  avoid  this,  the  greatest  watchfulness  is 
required  on  the  part  of  the  surgeon.  It  takes  the  patient 
longer  to  recover,  too,  and  he  may  sometimes  blame  the  sur- 
geon for  minor  operations  performed  to  avoid  amputation;  but 
the  final  results  more  than  justify  the  added  trouble. 

PRIMARY  TRANSFORMATION  OF  OPEN  GUNSHOT  THIGH 
FRACTURES    INTO    CLOSED    FRACTURES.— Lagoutte. 

Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  1546. 

In  seven  cases  Lagoutte  attempted  immediate  primary  re- 
union and  transformation  into  closed  fractures  of  open  frac- 
tures of  the  thigh.  Four  of  the  cases  were  successful.  The 
wound  was  cleansed  without  using  an  antiseptic.  These  cases 
were  treated  four  hours,  fourteen  hours,  seventeen  and  one- 
half  hours,  and  forty-nine  hours  respectively  after  injury.  In 
the  cases  which  did  not  give  good  results,  infection  had  already 
set  in  at  the  time  of  operation.  In  the  successful  cases  con- 
solidation was  effected  in  a  period  varying  from  25  to  42  days. 
The  steps  of  the  technic  are  radioscopic  examination;  wide 
opening  up  by  suitable  incisions;  extirpation  of  contused  tis- 
sues ;  vigorous  cleansing  of  the  bone  in  the  injured  area  and  re- 
moval of  free  and  devitalized  bone  chips ;  currettage ;  removal 
of  clots;  and  wiping  out  cavities.  After  complete  surgical 
cleansing  the  first  principle  to  observe  is  not  to  place  any 
foreign  body,  drain,  mesh,  etc.,  in  the  fractured  area.  To  en- 
sure evacuation  of  any  blood,  etc.,  the  first  sutures  need  not  be 
hermetic.  After  forty-eight  hours  if  there  is  no  temperature, 
nor  local  reaction,  the  sutures  are  drawn  tightly,  which  renders 


314  ABSTRACTS  OF  WAR  SURGERY 

the  closure  complete.  American  immobilization  apparatus  is 
used.  If  there  should  be  fistulization  a  simple  secondary  inter- 
vention is  called  for  to  remove  some  badly  tolerated  bone  chip, 
etc. 

INFECTED  GUNSHOT  INJURIES  OF  BONES  AND  JOINTS. 

— W.  Denk.    Wien.  klin.  Wchnschr.,  1915,  xxviii,  p.  701. 

In  the  treatment  of  infected  injuries  of  the  bones  and  joints 
every  possible  effort  should  be  made  to  save  the  limb.  In 
injuries  of  bones  if  there  is  no  gas  phlegmon  or  other  malignant 
infection,  expectant  treatment  is  indicated  at  first,  careful 
watch  being  kept  of  the  patient's  general  condition.  If  im- 
provement does  not  take  place  incision  with  removal  of  bone 
fragments  or  secondary  trough-shaped  osteotomy  is  indicated. 

The  indications  for  incision  and  removal  of  bone  fragments 
are :  continuous  high  fever,  putrid  suppuration,  signs  of  begin- 
ning sepsis,  hemorrhage,  and  streptococcus  infection.  After 
such  operations  care  must  be  taken  to  avoid  shortening  of 
the  extremity,  especially  the  lower.  It  is  well  to  keep  the  limb 
in  extension  with  moderate  weights  until  a  callus  is  formed. 

In  case  of  fistula  or  bone  abscess  sequestrotomy  and  trough- 
shaped  osteotomy  are  indicated.  The  periosteum  and  soft  parts 
are  inverted  into  the  trough  and  a  tampon  placed  over  them  to 
keep  them  in  place;  no  skin  incision  is  made.  The  trough  fills 
up  with  new-formed  bone,  as  is  shown  by  a  series  of  roentgen 
pictures.  To  avoid  spontaneous  fracture,  soon  after  the  operation 
a  fixation  dressing  is  applied  for  five  or  six  weeks. 

In  infected  gunshot  injuries  of  joints  conservative  treatment 
is  indicated.  Often  even  after  infection  in  the  joint  has  become 
manifest  it  is  sufficient  to  immobilize  the  limb  absolutely,  apply 
moist  dressings,  and  give  large  doses  of  salicylates.  If  this  treat- 
ment is  not  effective  arthrotomy  and  drainage,  with  the  opening 
of  any  periarticular  or  burrowing  abscesses,  are  indicated.  If 
this  treatment  is  not  successful,  resection  is  justified.  This  should 
also  be  the  primary  treatment  in  cases  with  severe  crushing  of 
the  ends  of  the  joints  and  virulent  infection  or  necrosis  of  frag- 
ments. If  all  conservative  methods  fail  or  if  the  patient's  life 
is  threatened  by  a  general  infection,  amputation  should  not  be 
delayed  too  long. 


ABSTRACTS  OF  WAR  SURGERY  315 

AN  IMPORTANT  POINT  IN  THE  TREATMENT  OF  GUN- 
SHOT FRACTURES.— G.  Perthes.  Miinchen.  med.  Wchnschr.. 
1915,  lxii,  p.  754. 

Perthes  calls  attention  to  the  fact  that  absolute  immobilization 
is  of  the  greatest  importance  in  the  treatment  of  fractures.  Many 
surgeons  seem  to  forget  this  in  dressing  and  the  fracture  is  moved 
during  the  dressing.  As  a  result  there  is  pain,  temperature,  and 
increase  in  wound  secretion.  This  is  almost  unavoidable  if  any 
of  the  numerous  forms  of  splint  are  used  that  have  to  be  removed 
during  the  dressing.  Fenestrated  plaster  casts  should  be  used 
which  allow  free  access  to  the  wound.  Illustrations  are  given  of 
casts  which  permit  this  and  also  protect  the  edges  of  the  window 
in  the  cast  against  being  soiled.  When  the  wound  has  healed  the 
usual  treatment  for  simple  fracture  can  be  applied. 

THE  PLATING  OF  GUNSHOT  FRACTURES.— N.  C.  Lake. 
Brit.  Med.  Jour.,  1915,  ii,  p.  44. 

The  questionable  practice  of  plating  in  compound  comminuted 
gunshot  fractures  among  wounds  is  dealt  with  interestingly  by 
the  author  in  a  recital  of  his  nine  months'  experience  at  the  front 
in  France.  He  did  not  see  it  used  in  any  of  the  French  military 
hospitals  that  he  visited  nor  did  he  hear  of  its  use  in  many 
English  ones. 

The  importance  of  obtaining  a  good  anatomical  result  in  the 
presence  of  comminuted  bone  and  the  difficulties  which  the 
latter  offers  is  fully  appreciated  by  the  author.  The  hindrance, 
from  the  presence  of  sepsis  which  is  found  in  all  cases,  is  also 
noted.  Lake 's  wide  experience  has  taught  him  that  fresh  infection 
of  soft  parts  is  negligible  in  view  of  the  already  extensive  damage, 
and  that  fresh  infection  of  the  bone  does  not  occur  to  any  extent 
worthy  of  consideration.  In  some  of  the  smaller  bones  a  previ- 
ously septic  wound  has  been  found  to  heal  completely  over  a  plate, 
a  fact  which  may  be  attributed  to  the  healthy  condition  of  the 
tissues  prior  to  the  injury.  In  most  cases,  however,  the  plates 
tend  to  loosen  in  the  presence  of  sepsis,  but  not  to  the  extent  he 
was  led  to  expect,  and  the  loosening  does  not  occur  to  an  extent 
sufficient  to  affect  the  original  object  of  the  plates  until  the 
fragments  have  become  partly  fixed,  in,  say,  two  or  three  weeks. 
The  plates  seem  to  have  little  effect  on  the  septic  process  and 
some  of  the  loose  ones  become  consolidated  again.     For  these 


316  ABSTRACTS  OP  WAR  SURGERY 

reasons  the  author  is  of  the  opinion  that  objections  to  the  use 
of  internal  splints  are  rather  theoretical  than  otherwise.  The 
ease  with  which  the  dressing  can  be  manipulated,  and  massage 
and  other  treatments  be  applied  to  neighboring  joints  and  soft 
tissues,  as  compared  to  a  limb  under  treatment  by  external  splints 
is  specially  noted. 

The  amount  of  comminution  necessitates  the  use  of  longer 
plates  than  those  in  ordinary  use.  In  some  shell  wounds  com- 
minution is  so  extensive  as  to  exclude  the  use  of  plates,  and  in 
these  cases  a  divided  plaster  having  a  soft  iron  connecting  piece 
bent  to  form  a  handle  to  manipulate  the  limb  is  found  to  be  of 
value. 

The  plating  operation  is  not  undertaken  until  acute  sepsis 
has  been  subdued  and  radiographs  have  been  taken — about  four 
days  after  admission.  The  taking  of  radiographs  in  two  planes, 
at  right  angles,  to  estimate  the  amount  of  destruction  and  to 
better  reconstruct  the  damage  done,  is  considered  very  essential. 
No  routine  method  is  used  to  combat  sepsis,  each  case  being 
treated  according  to  indications.  Ether,  a  dusting  powder  com- 
posed of  benzoic  acid  25  grams,  salol  5  grams,  quinine  25  grams,  and 
magnesium  carbonate  25  grams,  proved  of  use  in  very  dirty  cases 
after  a  preliminary  cleaning  under  an  anesthetic.  To  establish  the 
lymph  now,  as  recommended  by  Sir  Almroth  Wright,  hypertonic 
saline  solutions  with  and  without  vaccines  are  used;  but  once 
the  sepsis  is  limited,  more  reliance  is  placed  on  the  application  of 
a  Bier's  bandage  or  a  suction  cup  when  practicable.  Sun-baths 
and  injections  of  colloid  gold,  so  highly  recommended  by  French 
surgeons,  have  been  used  with  doubtful  results. 

By  the  energtic  use  of  the  methods  mentioned  sepsis  is  con- 
siderably reduced  after  a  few  days,  at  which  time  plating  can 
be  done.  In  most  of  the  war  wounds  an  incision  is  unnecessary 
or  the  original  wound  needs  to  be  only  enlarged.  The  good 
exposure  thus  obtained  is  an  advantage  in  point  of  drainage. 
The  fragments  are  carefully  replaced  except  those  entirely 
detached  that  must  obviously  die.  While  this  preliminary  arrange- 
ment is  being  made,  surrounding  structures  are  carefully 
examined  for  injury.  In  a  search  of  this  kind,  in  two  cases  of 
plating  of  the  humerus,  the  musculospiral  nerve  was  found 
in  such  a  position  that  it  would  later  have  been  involved  in  callus. 
It  was  promptly  freed  and  buried  in  muscle  to  prevent  symptoms 
of  pressure  later  on.  Many  such  cases  involving  tendons,  vessels, 
and  nerves  were  found  and  remedied  in  accordance  with  the 


ABSTRACTS  OF  WAR  SURGERY  317 

indications  offered.  After  exposing  the  ends  of  the  main  fragments 
the  plates  are  put  in  place  without  disturbing  the  periosteum 
unduly.  The  most  useful  plate  employed  was  one  having  two 
screw  holes  near  together  at  the  end,  with  one  or  two  intermediate 
ones.  The  latter  often  hold  intervening  small  fragments  in  good 
position.  It  is  preferable  not  to  put  screws  near  fractured  ends. 
Holes  are  carbolized  before  putting  the  screws  in  place.  Fresh 
incisions  may  be  closed,  although  they  may  be  left  open  a  few  days 
to  insure  drainage,  and  closed  by  suture  later.  The  limb  is  found 
quite  rigid  after  plating  and  the  subsequent  management  is  devoted 
to  keeping  down  sepsis  for  the  next  three  or  four  weeks.  The 
author  states  that  the  limb  may  be  treated  the  same  as  one  without 
fracture,  as  far  as  early  movements  and  massage  may  be  indicated. 
After  one  month  the  parts  have  become  solid  enough  so  that  any 
plates  that  show  a  tendency  to  be  loose  may  be  removed  except 
where  there  is  a  gap,  and  the  plate  is  then  retained  as  it  may 
assist  in  preventing  shortening.  Several  weeks  later  a  seques- 
trum is  found  embedded  in  a  cavity  of  bone  or  fibrous  tissue, 
which  should  be  removed.  To  close  the  remaining  cavity 
bismuth  paste  has  given  good  results.  Before  this  is  resorted 
to,  the  cavity  is  swabbed  with  pure  carbolic  acid,  and  iodoform 
paste  is  used  for  a  few  days.  Skin-grafting  was  often  resorted  to 
to  assist  in  rapid  closure  of  wounds. 

Many  cases  remained  ununited  except  by  deposit  of  fibrous 
tissue  between  the  bone-ends.  For  these  bone-grafting  is  recom- 
mended later. 

The  concluding  paragraph  should  convince  anyone  that  it 
will  be  a  long  time,  if  ever,  before  plating  becomes  an  adopted 
mode  of  treatment  in  gunshot  fractures  in  military  surgery. 
.  Even  in  simple  fractures  asepsis  has  always  been  the  sine  qua  non 
to  intervention.  Bone  tissue  at  best  offers  poor  resistance  against 
infection,  and  for  that  reason  the  propriety  of  plating  bone  in 
compound  fractures  has  always  been  questionable.  In  gunshot 
fractures  where  so  much  comminution  and  laceration  of  tissue 
exists  in  the  presence  of  heavy  infection,  and  amid  surroundings 
which  often  forbid  the  possibility  of  carrying  out  the  rules  of 
asepsis  completely,  as  is  found  in  the  emergency  conditions  of 
field  surgery,  the  practice  of  plating  at  best  could  only  be  under- 
taken by  experts  in  selected  cases. 

In  military  surgery  it  should  also  be  remembered  that  the  gaps 
which  are  apt  to  occur  in  the  continuity  of  the  long  bones  from 
shell  fracture  and  the  comminution  common  to  bullets  of  high 


818  ABSTRACTS  OF  WAR  SURGERY 

velocity,  have  hitherto  been  filled  in  a  surprising  way  by  new 
bone.  In  the  few  cases  in  which  Nature  fails  to  provide  the  bone; 
there  is  an  opportunity  of  replacing  the  intervening  fibrous  tissue 
with  bone  graft.  In  pseudoarthrosis  with  loss  of  bone  substance 
bone-grafting  offers  absolutely  safe  and  nearly  perfect  results. 
Lambotte  states  that  personally  he  has  never  resorted  to  a  muti- 
lating operation  for  pseudoarthrosis  from  loss  of  bone  substance. 
He  strongly  advocates  strict  asepsis  in  the  use  of  bone-grafting 
and  emphasizes  his  belief  that  living  bone  will  graft  itself  perfectly 
and  continue  to  live  in  its  natural  state,  and  this  is  especially  true 
of  autoplastic  grafts. 

THIGH  AMPUTATIONS  IN  WAR  SURGERY:  46  CASES.— A. 

Chalier.    Lyon  chir.,  1917,  xiv,  p.  591. 

Chalier  reports  46  thigh  amputations  for  gunshot  wounds, 
24  of  which  were  for  gaseous  gangrene,  with  9  deaths;  6  for  vas- 
cular gangrene,  with  2  deaths ;  5  of  secondary  hemorrhage  of  main 
vessels,  with  2  deaths;  and  11  for  early  or  late  septicemia,  with  2 
deaths. 

As  regards  technic,  Chalier  performed  2  flap  and  44  napless 
amputations.  Of  the  latter,  21  were  in  the  classical  manner, 
circular  and  funnel-shaped,  and  23  guillotine  amputations.  He 
prefers  this  last  method  in  emergency  cases,  such  as  gaseous 
gangrene,  because  it  occupies  the  least  amount  of  time,  permits 
the  greatest  possible  free  drainage,  and  saves  length  of  limb, 
the  skin  being  divided  at  the  lowest  possible  point. 

If  better  conditions  permit,  a  definite  operation  can  be  per- 
formed immediately,  and  the  author  employs  the  funnel-shaped  cir- 
cular or  the  flap  amputation.  In  6  cases  he  sutured  primarily  and 
had  5  successes. 

The  stump  is  immobilized  in  a  high  position  and  must  be  care- 
fully watched  during  the  first  days  if  the  operation  has  been 
done  for  gaseous  gangrene. 

As  regards  complications,  the  following  were  observed:  reten- 
tion of  pus  in  some  cases  of  crater-shaped  circular  amputations ; 
2  cases  of  gaseous  gangrene;  2  cases  of  tetanus  (1  fatal)  ;  4  cases 
of  phlebitis  of  stump;  and  3  cases  of  pulmonary  embolism,  2  of 
which  died. 

Five  stumps  needed  a  secondary  regularization  and  recovered 
within  ten  days  by  first  intention. 


ABSTRACTS  OF  WAR  SURGERY  31 9 

PRIMARY  RESECTION  IN  ARTICULAR  WOUNDS  OF  THE 
KNEE.— H.  P.  Rouvillois,  L.  Guillaume,  and  Basset.  Bull,  et 
mem.  Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  1364. 

In  197  cases  of  articular  wounds  of  the  knee  the  authors  per- 
formed primary  resection  11  times.  They  think  that  primary  re- 
section should  be  reserved  for  cases  of  articular  shattering.  Par- 
tial resection  with  the  ideal  technic  of  arciform  arthrotomy,  ap- 
pears applicable  in  a  wide  number  of  cases.  Extended  resection 
will  give  surprising  results  in  many  cases  which  from  bone  lesions 
alone  appear  condemned  to  amputation.  Every  doubtful  case 
should  be  resected  in  the  absence  of  important  vascular  or  soft 
part  lesions. 

In  dia-epiphysary  breakages  resection  is  the  operation  called  for ; 
this  should  be  atypical  and  follow  the  lesion.  The  nature  of  the 
resection  will  be  especially  determined  by  the  length  of  the  at- 
tacked diaphysis. 

In  uni-  and  bi-epiphysary  fractures  the  orthopedic  value  of  re- 
section is  incomparable,  as  it  gives  a  maximum  economy  of  the 
less  attacked  or  intact  epiphysis. 

Whatever  method  of  resection  is  adopted,  the  more  rapidly 
immobilization  is  resorted  to  the  better  will  be  the  results  when 
the  surfaces  are  strictly  adapted. 

FUNCTIONAL  VALUE  OF  THE  STUMP  AFTER  AMPU- 
TATION.—Tuffier.    Acad,  de  med.,  Paris,  1915,  lxxiv,  p.  786. 

A  second  operation  has  to  be  performed  in  a  great  many  ampu- 
tation cases.  Ninety  per  cent  of  these  secondary  operations  are 
on  the  lower  limb.  The  best  prophylactic  measure  is  early  and 
thorough  disinfection  of  wounds.  Wrong  methods  of  operation 
and  insufficient  after-treatment  are  responsible  for  a  certain  num- 
ber of  these  secondary  operations.  In  the  lower  limb  the  flap 
method  should  be  used  instead  of  the  circular  method,  for  it  gives 
a  more  supple  scar  and  one  which  is  not  located  at  the  end  of 
the  stump.  Elastic  traction  on  the  soft  parts  after  operation  will 
prevent  a  large  percentage  of  vicious  healing;  pain  due  to  the 
inclusion  of  nerves  may  be  avoided  by  a  little  care  in  cutting  the 
nerves  high  up.  Terminal  osteomyelitis,  which  frequently  neces- 
sitates a  second  amputation,  is  due  to  persistence  of  the  original 
infection. 

Disarticulation  at  the  hip-joint  gives  favorable  results  for  the 
wearing  of  an  artificial  limb.    Subtrochanteric  amputation  in  the 


320  ABSTRACTS  OF  WAR  SURGERY 

upper  fourth  of  the  femur  makes  the  adaptation  of  an  artificial 
leg  more  difficult,  but  it  is  a  less  serious  operation  than  disarticu- 
lation. A  stump  less  than  10  cm.  long  is  of  no  use  as  a  lever  in 
walking.  A  posterior  scar  is  much  better  than  the  scar  from  a 
circular  amputation  with  reference  to  fitting  the  artificial  leg,  but 
the  flap  method  necessitates  cutting  the  bone  higher  up  and  thus 
shortening  the  stump.  If  the  flap  method  does  not  change  an 
amputation  in  the  middle  third,  into  one  in  the  upper  third,  it 
should  be  given  the  preference  over  the  circular  method.  In- 
tracondyloid  amputations  give  good  results,  while  disarticulation 
of  the  knee  does  not.  Amputations  below  the  knee  should  be  as 
low  down  as  possible.  If  it  is  necessary  to  amputate  in  the  upper 
fourth  the  leg  should  be  removed  as  near  the  knee  as  possible, 
for  the  stump  is  useless  and  dangerous.  The  scars  of  amputa- 
tions below  the  knee  have  given  very  bad  results.  The  circu- 
lar method  should  be  entirely  abandoned;  a  posterior  flap  is  the 
best.  Tibiotarsal  disarticulation  and  intramalleolar  amputation 
enable  the  patient  to  walk  with  very  little  limping.  The  same 
is  true  of  Lisfranc's  and  Syme's  amputations;  but  Chopart's  am- 
putation almost  always  necessitates  secondary  operation  and 
should  be  used  only  in  exceptional  cases. 

Secondary  amputations  are  the  exception  in  the  arm,  so  the 
aim  here  is  to  preserve  as  much  of  the  limb  as  possible.  Intra- 
deltoid  amputation  is  much  preferable  to  disarticulation  of  the 
shoulder  for  it  makes  the  application  of  an  artificial  arm  much 
easier.  The  circular  method  is  preferable  in  the  arm,  because 
the  terminal  scar  does  not  have  to  bear  any  weight.  In  the  fore- 
arm it  is  especially  important  to  keep  as  long  a  stump  as  pos- 
sible. A  difference  of  three  or  four  centimeters  is  of  the  greatest 
importance  in  the  function  of  the  forearm.  At  the  wrist  a  pal- 
mar flap  is  preferable  to  the  circular  method.  In  any  amputation 
it  is  of  great  importance  to  preserve  the  function  of  the  adjacent 
joint  by  early  mobilization. 

TREATMENT  OF  COMPLICATED  GUNSHOT  FRACTURES  OF 
THE  HUMERAL  DIAPHYSIS.— H.  Alamartine.  Lyon  Chir., 
1916,  xiii,  p.  877. 

The  treatment  of  complicated  gunshot  fractures  of  the  humeral 
diaphysis  differs  considerably  from  that  of  the  same  fractures 
observed  in  civil  practice.  In  the  two  cases  the  lesions  are  very 
dissimilar. 

In  war  surgery  the  vulnerable  agents  are  driven  by  enormous 


ABSTRACTS  OF  WAR  SURGERY  321 

force  and    produce    special  destruction.      The  condition    of  the 
wounded  and  the  surgical  means  at  disposal  are  also  very  spe- 
cial.   These  demand  special  methods  of  treatment. 
The  fractures  are  of  different  types : 

1.  Benign  type,  due  to  small  projectile  or  projectile  of  reduced 
velocity.  In  this,  lesion  of  the  radial  nerve  is  the  only  usual 
element  of  gravity. 

2.  Grave  type  :  (a)  shattering,  due  to  small  projectile  with  con- 
siderable velocity.  The  osseous  lesion  is  extended  and  grave. 
Many  spiculas  are  in  the  region;  (b)  crushing,  due  to  large  pro- 
jectile acting  by  its  mass.  Extensive  injuries  of  the  soft  parts. 
The  spicule  are  adherent. 

3.  Very  severe  type :  Destructive  crushing  of  the  upper  limb, 
or  with  complications  such  as  gas  gangrene,  etc.,  which  ordinar- 
ily call  for  amputation. 

Treatment  as  far  as  possible  should  be  conservative.  A  con- 
siderable functional  restoration  is  compatible  with  extensive  muti- 
lation and  even  with  a  very  defective  consolidation. 

Continuous  extension  is  the  best  method  to  obtain  reduction, 
using  Delbet's  apparatus.  Sequestrotomies,  followed  or  not  by 
osteosynthesis,  at  times  may  be  necessary.  Early  treatment, 
either  at  the  first  aid  or  in  the  surgical  ambulance,  consists  of 
wide  and  early  surgical  disinfection,  removal  of  foreign  bodies, 
etc.;  immobilization  of  the  fractured  limb  (Delorme's  thoraeo- 
brachial  splint). 

Osseous  interventions,  sequestrotomies,  etc.,  also  continuous  ex- 
tension, when  required,  are  carried  out  in  the  base  hospitals. 

EARLY  TREATMENT  OF  COMPOUND  FRACTURE  OF  THE 
LONG  BONES  OF  THE  EXTREMITIES.— B.  Hughes.  Brit. 
Med.  Jour.,  1917,  i,  p.  289. 

Upon  what  is  done  for  men  suffering  from  compound  fractures 
of  the  longer  bones  of  the  extremities  in  the  hours  immediately 
following  their  infliction  depends  to  a  great  extent  their  subse- 
quent utility,  and  often  their  life. 

In  the  case  of  a  man  wounded  in  action,  one  must  consider: 
(1)  fatigue;  (2)  shock  (especially  in  fractures  involving  the 
femur);    (3)  local  tissue  stupor;    (4)  infection. 

Local  tissue  stupor  is  brought  about  in  the  muscles  and  other 
soft  structures  as  a  result  of  injury  caused  by  a  piece  of  shell. 
The  naked-eye  appearance  of  such  tissue  is  characteristic.  The 
muscle  looks  dry  and  lifeless,  it  is  quite  insensitive,  does  not  bleed 


322  ABSTRACTS  OF  WAR  SURGERY 

when  cut,  and  does  not  contract  when  stimulated.  This  tissue, 
though  not  dead,  is  very  apt  to  die,  and  while  in  this  stunned 
state  is  very  prone  to  infection.  If  a  tourniquet  be  applied  to  the 
limb  above  such  tissue,  or  if  antiseptics  be  used,  gangrene  is  al- 
most certain  to  ensue.  Under  these  conditions,  if  necessary,  a 
limb  can  be  amputated  quite  painlessly. 

All  shell  wounds  are  bound  to  become  infected,  whatever  care 
be  taken.  The  bacteria  most  to  be  feared  are:  (1)  bacillus  per- 
fringens,  (2)  Vincent's  bacillus,  (3)  bacillus  tetanus,  and  (4) 
streptococcus  fecalis. 

It  is  therefore  important  as  early  as  possible  to  follow  out  the 
rules  applying  to  open  wounds:  (1)  prevent  further  infection; 
(2)  get  rid,  as  far  as  possible,  of  infection  already  carried  in; 
and,  in  cases  of  fracture,  a  third  may  be  added :  (3)  prevent  what 
infection  has  already  been  carried  in  from  becoming  further  dis- 
seminated by  thoroughly  immobilizing  the  limb. 

The  author  states  that  quite  a  number  of  wounds  have  become 
fly-blown,  and  that  the  presence  of  maggots  in  such  wounds  seems 
to  exert  an  inhibitory  action  on  the  growth  of  the  more  virulent 
bacteria,  and  so  acts  beneficially.  Maggots  thrive  only  in  dead 
tissue,  and  seem  to  hasten  its  removal.  Two  of  the  worst  but- 
tock wounds  seen  by  the  author  became  accidentally  fly-blown,  and 
from  the  time  of  the  appearance  of  the  maggots  both  cases  began 
to  improve. 

Motor  transport  from  the  advanced  dressing  station  to  the  field 
ambulance  has,  as  a  rule,  to  be  as  rapid  as  possible,  owing  to 
enemy  shell  fire.  This  necessitates  shaking,  and  brings  into 
prominence  other  complications;  (1)  embolism  (pulmonary)  ;  (2) 
increased  shock;  (3)  increased  damage  to  tissue  and  so  further 
dissemination  of  infection;  (4)  hemorrhage.  From  the  field  am- 
bulance these  men  proceed  by  motor  to  the  casualty  clearing  sta- 
tion, often  a  considerable  journey.  The  condition  of  their  wounds 
on  arrival  will  depend  upon  the  length  of  time  they  have  been 
wounded  and  the  manner  in  which  the  fracture  has  been  im- 
mobilized. Perfect  immobilization,  as  early  as  possible,  in  the 
position  in  which  the  fractured  limb  is  found,  whether  in  trenches 
or  in  the  open,  is  the  first  essential  to  success.  If  a  limb  is  hope- 
lessly shattered,  with  vessels  and  nerves  divided,  it  is  wiser  to 
amputate  at  once  at  the  regimental  aid  post,  and  tie  the  main 
vessels.  Owing  to  tissue  stupor  the  operation  is  painless,  and 
the  risk  of  shock  and  fatal  hemorrhage  during  transport  is 
avoided.     Tourniquets  for  transport  should  not  be  used.    They 


ABSTRACTS  OF  WAR  SURGERY  323 

tend  to  slip;  they  are  painful,  and  increase  shock;  and  they 
cause  irretrievable  damage  to  the  tissues  they  constrict. 

The  author  discusses  treatment  at  casualty  clearing  stations 
and  describes  various  practical  splints.  For  the  femur  a  rifle 
padded  with  sandbags  or  a  great-coat  is  placed  with  the  butt 
end  in  the  axilla,  Fractures  of  the  humerus  can  be  immobil- 
ized with  rolled  sandbags  strengthened  with  entrenching-tool 
handles.  Splints  of  special  designs  suitable  for  treatment  at 
the  casualty  clearing  station,  and  applicable  to  the  femur,  leg, 
humerus,  and  forearm,  are  described  and  illustrated. 

As  to  the  dressing,  if  the  wound  be  extensive,  that  used  for 
the  first  few  days  before  sending  these  cases  to  the  base  has 
either  been  a  salt  pack  or  Carrel's  tubes  with  Dakin's  solution. 
The  latter  method  requires  more  time,  and  can  only  be  under- 
taken when  there  is  not  an  undue  rush  of  casualties.  The 
salt  pack  has  given  good  results,  and  does  not  require  the  same 
amount  of  attention. 

The  aftertreatment  is  described  in  detail.  If  infection  still 
persists  in  the  wound,  and  is  spreading,  though  not  sufficiently 
to  threaten  life,  treatment  will  depend  upon  the  organism  pres- 
ent. If  bacillus  perfringens  and  streptococcus  fecalis  (for  these 
two  organisms  generally  coexist)  be  the  cause,  then  a  barrier 
of  hydrogen  peroxide  or  potassium  permanganate  (strong  solu- 
tion) injected  into  sound  tissue  above  and  below  the  infected 
area,  and  completely  encircling  the  limb,  has  done  good  in 
some  cases  and  sufficed  to  arrest  further  spread.  In  a  few 
desperate  cases  the  author  has  tried  intravenous  injections  of 
eusol,  as  recommended  by  Fraser  and  Bates,  but  has  had  no 
success  from  its  use. 

SECONDARY  SUTURE  OF  THE  WOUND  IN  CASES  OF 
OPEN  FRACTURE.— Depage  and  Vandervelde.  Bull,  et 
mem.  Soc.  de  chir.  de  Paris,  1917,  xliii,  p.  477. 

In  treating  open  fractures  in  their  ambulance  service,  by 
rigorously  following  the  Carrel  method  after  preliminary  strip- 
ping and  clearance  of  the  wound,  the  authors  have  been  able 
to  sterilize  wounds  after  a  lapse  of  time  varying  from  fifteen 
days  to  a  month,  and  to  definitely  close  them  without  acci- 
dent. In  effecting  the  change  from  an  open  to  a  closed  frac- 
ture not  only  the  time  of  treatment,  but  also  that  of  recovery 
of  normal  function,  has  been  shortened.  The  method  pursued 
may  be  summed  up  as  follows : 


324  ABSTRACTS  OF  WAR  SURGERY 

1.  On  arrival  of  the  patient  (in  from  two  to  six  hours  after 
being  wounded)  the  fractured  area  is  opened  up,  cleansed  and 
cleared,  leaving  only  such  bone  fragments  as  are  clearly  vital. 
Carrel  tubes  are  then  placed  in  position. 

2.  The  wound  is  irrigated  every  two  hours  by  Dakin's  fluid 
(Carrel's  prescription). 

3.  The  dressings  are  renewed  every  day,  the  wound  being 
cleaned  at  the  same  time. 

4.  Bacteriologic  control  is  noted  every  two  days.  When  the 
microbian  curve  remains  at  zero  after  two  or  three  examinations 
the  wound  is  sutured. 

5.  Suture  is  effected  after  freshening  the  edges  and  remov- 
ing any  cicatricial  tissue. 

The  authors  proceeded  cautiously  to  suture  in  their  cases 
early;  but  since  November  last  all  fractures  which  have  been 
stripped  and  cleared  are  regularly  closed.  They  have  operated 
upon  75  such  cases. 

The  authors'  conclusions  are  that  an  open  fracture  can  re- 
cover aseptically.  They  do  not  know  whether  the  Carrel  method 
is  the  only  one  capable  of  giving  this  result,  but  it  is  the  only 
one  that  has  given  proof  of  it. 

DIAGNOSIS  OF  SUPPURATIVE  ARTHRITIS  FOLLOWING 
GUNSHOT  FRACTURES.— M.  Chaput.  Presse  med.,  1915, 
xxiii,  p.  124. 

Gunshot  fractures  are  very  frequently  complicated  by  sup- 
purative arthritis  and  often  this  complication  is  not  diagnosed. 
Chaput  says  that  9  out  of  10  fractures  of  the  epiphysis  involve 
the  joint.  If  there  is  a  fistula  through  which  the  pus  is  dis- 
charged the  case  may  be  afebrile  but  the  patient  becomes 
cachectic  from  gradual  absorption  of  septic  material.  Some 
patients  die  from  an  acute  attack  following  the  closing  up  of 
the  external  opening  of  the  fistula,  some  become  affected  with 
severe  erysipelas,  and  some  die  of  septic  embolism. 

When  the  fracture  is  of  the  diaphysis,  diagnosis  of  a  joint 
complication  is  more  difficult.  Sometimes  if  the  fracture  is 
opened  up  and  examined  carefully  a  minute  fissure  leading  to 
the  joint  will  be  discovered.  A  further  test  may  be  made  by 
injecting  sterilized  methylene  blue  1 :1000  into  the  joint  until 
the  synovial  membrane  is  slightly  distended;  in  a  few  seconds 
the  blue  color  will  appear  at  the  fracture,  showing  that  there 
is  a  communication  with  the  joint.    After  a  diagnosis  has  been 


ABSTRACTS  OP  WAR  SURGERY  325 

made  in  one  of  these  ways  a  considerable  number  of  times,  it 
will  be  found  that  whenever  a  juxta-artieular  fracture  prop- 
erly drained  still  causes  fever,  it  is  almost  always  complicated 
by  joint  infection.  Sometimes  even  when  there  is  no  pus  in 
the  joint  the  bones  will  be  found  friable  and  the  cartilages, 
ligaments,  and  synovial  sac  will  have  a  violet  color,  showing 
infection. 

TREATMENT  OF  GUNSHOT  INJURIES  OF  THE  EXTREMI- 
TIES.— Axhausen.  Deutsch.  med.  Wchnschr.,  1915,  xli,  p. 
640. 

Conservative  treatment  of  injuries  of  the  extremities  is  rec- 
ommended in  the  textbooks  on  military  surgery.  Axhausen 
practiced  this  during  the  first  few  months  of  the  war  and  was 
appalled  at  the  number  of  infections  resulting.  He  thinks  this 
is  due  to  the  fact  that  the  wounds  in  this  war  are  of  a  differ- 
ent character  from  those  of  previous  wars.  There  is  much  more 
crushing  and  mangling  of  the  tissues,  owing  to  the  conditions 
in  the  trenches  and  the  high  percentage  of  wounds  from  artil- 
lery fire. 

For  the  past  few  months  the  author  has  adopted  an  entirely 
different  treatment.  The  cases  with  much  destruction  of  tis- 
sue are  taken  in  hand  at  once.  The  crushed  skin  and  tissues 
are  removed,  till  there  is  a  clean  bleeding  surface  over  the 
whole  wound;  all  foreign  bodies,  including  fragments  of  shat- 
tered bone  are  removed ;  fractured  ends  of  bone  are  brought  to- 
gether and  sutured  with  silver  wire.  Muscles  and  nerves  are 
sutured  after  proper  freshening  and  the  ends  of  the  nerves  are 
embedded  in  muscle  tissue.  The  wound  is  tamponed,  drainage 
and  counter-drainage  established,  the  skin  wound  sutured,  and 
the  limb  immobilized. 

He  believes  that  it  is  not  necessary  to  observe  the  strict 
asepsis  demanded  in  civil  practice.  He  sterilizes  his  instruments 
at  the  beginning  of  his  day's  work  and  then  uses  them  on  dif- 
ferent cases  without  further  sterilization.  He  also  sterilizes  his 
hands  thoroughly  once  and  then  washes  them  only  between 
cases.  It  is  only  necessary  to  help  the  natural  forces  of  the 
body  by  coarse  mechanical  measures.  The  time  saved  by  omit- 
ting the  finer  details  of  asepsis  enables  him  to  care  for  many 
more  cases. 

He  has  not  had  a  single  case  of  tetanus  or  gas  phlegmon  fol- 
lowing this  treatment.     In  all  cases  the  temperature  soon  fell 


326  ABSTRACTS  OF  WAR  SURGERY 

and  the  tampons  and  drains  could  be  removed  on  the  eighth  to 
the  twelfth  day. 

He  describes  a  typical  case — that  of  an  officer  who  had  a  des- 
tructive wound  of  the  right  elbow,  involving  the  ulnar  nerve. 
He  treated  it  in  November  and  by  January  the  functional  use 
of  the  nerve  was  restored  without  a  sign  of  paralysis  or  con- 
tracture. In  injuries  with  much  destruction  of  tissue,  this 
method  of  treatment  is  much  superior  to  the  older  conservative 
method. 

TREATMENT  OF  GUNSHOT  FRACTURES  OF  THE  EX- 
TREMITIES IN  WAR.— G.  von  Saar.  Beitr.  z.  klin.  Chir., 
1914,  xci,  p.  351. 

Von  Saar  reports  one  month's  service  in  the  reserve  hospital 
in  Belgrade.  He  says  that  injuries  of  the  extremities  comprise 
between  one-half  and  three-fourths  of  all  injuries,  while  gun- 
shot fractures  comprise  about  one-fifth  of  all  injuries. 

Among  518  injuries  of  the  extremities  von  Saar  observed  84 
fractures,  40  of  the  upper,  44  of  the  lower  extremity.  He  holds  that 
roentgen  examination,  while  very  interesting  from  a  scientific 
point  of  view,  may  be  dispensed  with  for  fracture  treatment 
even  in  stationary  hospitals.  He  lays  the  greatest  emphasis  on 
improvised  methods  with  simple  means.  High  fractures  of  the 
humerus  should  be  treated  with  Christen 's  double  right-angled 
splints  and  double  extension  traction.  Fractures  of  the  forearm 
are  also  treated  by  extension  to  avoid  a  fracture  callus,  and 
by  a  simple  right-angled  splint  similar  to  Borchgrevink's.  The 
results  of  the  extension  treatment  are  good. 

In  fractures  of  the  lower  extremities  von  Saar  points  out 
that  not  only  the  first  dressing  but  also  the  further  treatment 
is  of  great  importance.  In  treating  fractures  of  the  femur 
Florsehutz's  method  is  used,  which  combines  semiflexion  suspen- 
sion, and  extension. 

As  a  transportation  dressing  for  fractures  of  the  femur  he 
recommends  von  Hacker's,  which  consists  of  a  long  strip  of 
wood  as  broad  as  two  fingers,  provided  above  with  a  notch  and 
below  with  a  nail.  It  is  applied  to  the  side,  reaching  from  the 
umbilicus  down  to  the  foot,  and  provides  for  simple  extension. 
This  is  practically  the  same  as  the  old  Esmarch's  transport 
dressing  for  fractures  of  the  femur. 

Mention  is  made  of  Weissenstein 's  adaptation  of  the  military 
stretcher  for  the  transportation  of  fractures  of  the  lower  ex- 


ABSTRACTS  OP  WAR  SURGERY  327 

tremity,  in  which  the  stretcher  rods  are  used  as  external 
splints.  In  fractures  of  the  leg  he  recommends  for  the  infected 
cases  fenestrated  plaster  casts;  for  the  noninfected,  the  splint 
extension  with  traction  on  the  upper  part  of  the  shoe,  especially 
in  fractures  of  the  lower  third.  In  general,  he  recommends 
plaster  casts  only  when  infection  renders  frequent  changing 
of  the  dressings  necessary.  He  discusses  the  "Introduction  to 
Military  Surgery  on  the  Battle-Field, "  issued  to  the  Austrian 
army,  in  which  he  thinks  too  much  importance  is  attached  to 
plaster  and  papier  mache  dressings. 

TEN  RULES  FOR  AMPUTATIONS  OF  THE  LOWER  LIMBS. 

— -R.  Ritschl.  Med.  Klin.,  1915,  xi,  p.  1270. 

Ritschl  gives  the  following  ten  rules  for  amputations  of  the 
lower  limbs : 

1.  It  is  of  great  importance  that  the  stump  should  be  capable 
of  bearing  the  weight  of  the  body;  this  keeps  it  strong  as  well 
as  avoiding  artificial  supporting  surfaces,  which  are  of  less 
value. 

2.  A  circular  incision  seldom  gives  a  weight-bearing  stump, 
because  it  makes  the  scar  pass  across  the  end  of  the  bone. 

3.  "Whenever  possible  flap  methods  should  be  used,  care  being 
taken  to  make  as  small  a  scar  as  possible  on  the  lateral  surface 
of  the  stump. 

4.  By  removing  the  periosteum  and  bone-marrow  for  1  to  2  cm. 
the  stump  can  be  made  painless. 

5.  As  soon  as  the  wound  is  healed  the  stump  should  be  hardened 
with  baths,  alcohol  rubs,  massage,  and  using  it  on  crutches. 

6.  The  muscles  of  the  rest  of  the  limb  should  be  strengthened 
by  active  gymnastics,  and  the  joints  should  be  kept  active  by 
passive  movements. 

7.  As  soon  as  possible  the  patient  should  be  provided  with  an 
artificial  limb. 

8.  If  the  amputation  was  above  the  knee  the  artificial  leg  should 
be  provided  with  a  knee-joint. 

9.  The  uninjured  limb  must  be  kept  from  atrophy  by  gymnastic 
exercise  while  the  patient  is  in  bed,  as  greater  demands  than 
usual  will  be  made  on  it  later. 

10.  For  the  same  reason  any  decreased  functional  capacity  of 
the  uninjured  limb  should  be  given  especial  attention  and  treat- 
ment, such  as  active  gymnastics  and  orthopedic  treatment  for 
actual  or  threatened  flat-foot. 


BURNS 

PARAFFIN  TREATMENT  OF  BURNS.— Maj.  Geo.  de  Tarnow- 
sky.    (In  a  report  to  the  Surgeon-General.) 

"Parowax"  (a  trade  name  applied  to  paraffin  marketed  by  the 
Standard  Oil  Company,  of  Indiana)  ;  "Paraffin  120-122,  F,"  (put 
up  by  the  same  company),  and  formula  No.  21  {Jour.  Am.  Med. 
Assn.,  May  19,  1917,  p.  1499),  consisting  of: 

Paraffin,    120-122    F 97.5  gms. 

Olive   Oil    1.5  gms. 

Asphalt   4  drops 

all  fulfil  the  above  requirements.  The  addition  of  two  per  cent 
eucalyptus  oil,  or  of  some  other  pleasant  deodorant,  is  very  grate- 
ful to  most  patients. 

Technic. — 

1.  Place  the  paraffin  cake  in  a  sterile  metal  container  and  heat 
over  a  flame.  A  quick  and  practical  way  of  estimating  the  proper 
temperature  is  to  thoroughly  melt  the  entire  cake,  stirring  occa- 
sionally with  a  sterile  glass  rod  or  sterile  metal  instrument.  By 
waiting  until  the  paraffin  begins  to  show  a  solidifying  film  upon  the 
surface,  one  obviates  the  danger  of  overheating. 

2.  With  a  soft  cotton  mop  (a  piece  of  absorbent  cotton  grasped 
in  the  bite  of  forceps  answers  very  well)  sop — do  not  rub  the 
entire  surface  of  the  burn. 

3.  Place  a  thin  layer  (i/8  inch)  of  absorbent  cotton,  cut  the 
same  size  as  the  area  of  the  burn,  over  the  wound  after  the  first 
layer  of  paraffin  has  been  applied. 

4.  Cover  the  cotton  with  a  second  layer  of  paraffin.  This  may 
be  more  rapidly  painted  on  by  means  of  a  broad  soft  camel-hair 
brush. 

5.  Apply  a  thick  layer  of  cotton  and  a  light  bandage. 

6.  Immobilize  the  area  whenever  possible. 
Formula  for  white  wax  type  (Tarnowsky)  : 

White  precipitate  of  mercury 5  per  cent 

Zinc  oxide  ointment  70  per  cent 

White  wax 25  per  cent 

328 


ABSTRACTS  OF  WAR  SURGERY  329 

The  melting  point  is  approximately  that  of  the  paraffin  mix- 
tures, and  its  application  the  same.  Stock  dressings  may  also  be 
prepared  with  the  same  formula  and  kept  on  hand,  ready  for 
instant  use. 

Preparation  of  Stock  Dressings. — 

1.  Sterilize  by  boiling  a  sufficient  quantity  of  the  above  formula. 

2.  Cut  strips  of  gauze  of  varying  width  and  length. 

3.  Pick  up  each  strip  of  gauze  with  forceps,  allowing  it  to  un- 
roll its  full  length ;  dip  same  in  the  boiling  liquid ;  allow  the  excess 
to  drain  back  into  the  vessel  and  drop  the  impregnated  gauze  into  a 
sterile  jar. 

4.  Do  not  pack  the  jar  tightly.  Close  and  seal  jar  as  soon  as 
full.  When  required,  pick  up  a  piece  of  impregnated  gauze  by 
means  of  a  sterile  forceps  and  lay  it  lightly  over  the  previously 
prepared  burnt  area. 

When  the  second  dressing  is  made,  either  in  the  Field  or  Evacua- 
tion Hospital,  the  degree  and  extent  of  the  burn  and  the  probable 
additional  treatment  required,  should  be  estimated.  Burns  of  the 
first  degree  and  all  burns  of  the  second  degree  not  requiring  graft- 
ing should  be  kept  in  the  zone  of  the  advance  or  zone  of  the  line 
of  communications.  Burns  requiring  grafting,  burns  of  the  third 
degree,  and  those  complicated  by  severe  wounds  (deep  lacera- 
tions, compound  fractures,  etc.)  belong  to  the  Base  Hospitals. 

Skin-grafting  will  be  required  in  second  and  third  degree  burns 
of:  (1)  Face,  neck;  (2)  Hands;  (3)  Immediate  vicinity  of 
joints. 

When  should  grafting  be  resorted  to? — As  soon  as  sloughing  of 
burnt  tissues  has  ceased.  The  presence  of  slight  amounts  of  pus 
is  not  a  contraindication. 

Types  of  Graft. —  (a)  Thiersch  or  Eeverdin  (superficial  defects)  ; 
(b)   Skin-flap  (deep  defects). 

A.  Thiersch  or  Reverdin. — 

1.  The  sooner  the  grafts  are  applied,  the  greater  the  percentage 
of  "takes." 

2.  Grafts  applied  late,  over  granulating  surfaces  seldom  "take"; 
if  they  do  they  are  apt  to  die  subsequently  as  the  granulations 
under  them  contract  and  shut  off  their  blood  supply. 

3.  Protect  the  grafts  by  applying  thin  strips  of  gutta-percha 
tissue  over  them  ' '  criss-cross ' ' ;  over  this  lay  gauze  impregnated 
with  paraffin  or  wax-mixture. 


330  ABSTRACTS  OF  WAR  SURGERY 

4.  Do  not  disturb  the  dressing  for  several  days. 

5.  A  wire  netting  cage  protecting  the  burnt  area  obviates  the 
necessity  of  a  dressing  and  gives  the  best  results.  It  is  not  always 
possible  to  devise  such  a  cage. 

B.  Skin  Flap.- — (1)  One-step  method  (transplantation)  ;  (2) 
Two-step  method. 

1.  The  entire  thickness  of  the  skin,  including  adipose  tissue, 
should  be  used.  It  is  only  successful  if  done  early,  and  if  the  vas- 
cularity of  the  burn  is  good  and  hyperemia  can  be  maintained. 

2.  The  two-step  or  flap  method  is  always  reliable  and  should  be 
selected  whenever  the  location  of  the  burn  makes  it  possible.  An 
interval  of  ten  to  fourteen  days  should  elapse  between  the  two  steps 
and  immobilization  of  the  flap  should  be  absolute.  The  margin  of 
the  burn  should  be  trimmed  vertically  (at  right-angle  to  skin  sur- 
face) the  flap  sutured  at  its  free  margin  and  laterally,  the  sutures 
should  be  interrupted  without  tension,  and  the  wound  covered  with 
impregnated  gauze  which  is  usually  not  changed  until  the  second 
step  is  completed.  Be  sure  to  allow  for  retraction  of  the  flap.  (25 
per  cent  margin  is  a  safe  one  to  go  by) . 

Prevention  of  Contractures  and  Disfiguring  Scars. — 

1.  By  early  and  complete  grafting. 

2.  By  means  of  casts  or  splints. 

(a)  Immobilize  in  flexion,  burns  of: 

1.  Posterior  surface  of  elbows. 

2.  Dorsal  surface  of  wrist,  hand  or  fingers. 

3.  Anterior  patellar  region. 

(b)  Immobilize  in  extension,  burns  of: 

1.  Antero-lateral  aspect  of  neck. 

2.  Anterior  surface  of  elbow. 

3.  Palmar  aspect  of  wrist,  hand  and  fingers. 

4.  Popliteal  space. 

(c)  Immobilize  in  abduction,  burns  of: 

1.  The  axilla. 

2.  The  crotch. 
Summary. — 

1.  Do  not  scrub  off  the  epidermal  cells  with  soap,  water  and 
brush. 

2.  Leave  burns  of  the  first  degree  to  nature  as  far  as  possible. 

3.  If  grafting  be  necessary,  resort  to  it  as  early  as  possible,  even 
in  the  presence  of  a  slight  amount  of  pus. 

4.  The  open-air  treatment  of  burns  of  all  degrees  gives  the  best 
results. 


ABSTRACTS  OF  WAR  SURGERY  331 

5.  If  the  open-air  treatment  is  not  practicable,  always  use  a  bland 
nonadherent  type  of  dressing  and  change  the  dressings  as  seldom 
as  possible. 

6.  Beware  of  contractures  and  disfiguring  scars.  Proper 
splinting  will  always,  proper  grafting  will  often  obviate  this 
calamity. 

PARAFFIN  IN  THE  TREATMENT  OF  WOUNDS  AND 
BURNS.  OBSERVATIONS  ON  VARIOUS  PREPARA- 
TIONS.—J.  B.  Beiter.    Jour.  Am.  Med.  Assn.,  lxviii,  p.  1801. 

The  successes  claimed  for  "Ambrine"  in  the  treatment  of  burns 
promised  a  large  field  in  industrial  accidents  and  therefore 
prompted  extensive  trials.  Owing  to  my  inability  to  obtain 
''Ambrine,"  various  paraffin  compounds  were  used  —  formulas 
containing  eucalyptus,  resorcin,  betanaphthol,  resin,  cora  flava, 
olive  oil,  and  scarlet  red,  in  ordinary  paraffin.  My  series  of  cases 
represents  over  4,000  wax  dressings  on  every  conceivable  burn, 
and  many  lacerated  wounds. 

Prior  to  the  employment  of  the  wax  treatment  of  burns  we  had 
employed  the  usual  methods — various  ointments,  various  aqueous 
solutions,  the  bath  treatment,  exposure  to  the  air,  and  picric 
acid. 

Our  technic  in  the  use  of  waxes  was  as  follows :  All  burns  were 
carefully  cleaned  at  our  emergency  hospital  by  well  trained  men, 
any  blebs  were  opened,  and  all  the  skin  that  could  be  taken  off 
with  ease  was  removed.  The  burned  area  was  dried  either  by  ex- 
posure to  air  or  by  gently  wiping  the  surface  with  cotton  pledgets 
dipped  in  ether.  Over  the  involved  area  a  thin  film  of  the  wax  was 
painted.  (The  wax  is  kept  constantly  in  a  water  bath,  so  that  it 
is  at  all  times  ready  for  instant  use.)  Over  the  wax  film  a  thin 
layer  of  cotton  or  a  split  piece  of  sheet  wadding  was  placed  and  a 
second  film  of  wax  was  painted,  sealing  it  to  the  skin  at  the  edges 
of  the  cotton  dressing.  Over  this  a  heavier  cotton  dressing  was 
applied  and  then  the  bandage.  We  found  that  if  the  injured  sur- 
face was  wet  or  damp  the  first  paraffin  film  would  not  adhere. 

We  began  with  the  various  paraffin  mixtures  enumerated  above ; 
but  we  failed  to  see  any  differences,  except  some  disagreeable  fea- 
tures with  the  resin  mixtures.  For  example,  the  undissolved  resin 
sank  to  the  bottom  of  our  warming  receptacle  and  injured  the  brush 
with  which  the  wax  was  applied,  making  the  application  to  the  in- 


332  ABSTRACTS  OF  WAR  SURGERY 

jured  surface  painful.  We  therefore  discarded  all  drugs  in  our 
wax  and  used  the  commercial  ' '  Parowax, ' '  applied  as  above. 

This  was  sometimes  tinted  pink  with  scarlet  red  simply  for  cos- 
metic reasons. 

The  question  of  melting  point  was  at  first  an  important  one,  be- 
cause to  apply  a  hot  solution  to  a  large  area  of  denuded  nerve 
endings  usually  brought  a  prompt  and  energetic  reaction,  and  to 
wait  until  the  wax  cooled  to  the  extent  that  a  film  formed  over  it 
meant  that  it  would  cool  below  the  liquid  state  before  it  could 
be  applied.  However,  the  water  bath  or  household  double  boiler 
holds  the  melting  point  very  well. 

A  suggestion  made  to  me  by  Dr.  Terald  Sollamann  has  elimi- 
nated the  importance  of  melting  point  temperature  entirely  and 
greatly  simplified  the  dressing  as  well  as  adding  to  the  comfort  of 
the  patient  at  the  time  of  the  dressing,  and  in  no  way  changing  the 
results.  His  suggestion  was  that  the  wounds  be  painted  with 
liquid  petrolatum,  further  treatment  proceeding  as  with  the  wax. 
In  this  method  a  layer  of  liquid  petrolatum  and  then  the  cotton  or 
sheet  wadding  are  placed  over  the  injured  area  before  the  warm 
paraffin  is  painted  on  the  dressing.  This  method  has  been  followed 
in  all  of  our  recent  cases  and  is  greatly  appreciated  by  the  patients 
who  are  the  court  of  last  appeal.  It  is  essential  that  the  dressing 
adhere  at  least  to  the  skin  about  the  edges  of  the  dressing ;  other- 
wise the  secretions  are  pouring  out  over  the  intact  skin  and  excor- 
iating it,  soiling  the  dressings  and  making  a  disagreeable  odor. 

Advantages  of  the  Wax  Treatment  of  Burns. — 1.  It  is  an  inex- 
pensive dressing ;  a  pound  of  wax  and  a  pint  of  liquid  petrolatum 
together  costing  about  65  cents,  will  dress  many  burns.  It  replaces 
the  gauze  which  at  this  time  is  quite  expensive. 

2.  It  is  a  comfortable  dressing  because  it  is  firm  and  smooth,  and 
the  granulating  surface  does  not  grow  through  it  as  with  the  gauze. 
The  paraffin  is  hard  enough  to  make  the  dressing  somewhat  rigid 
and  acts  as  a  splint. 

3.  It  is  a  cleaner  dressing  than  any  I  have  used  because  the 
wound  discharge  is  not  permitted  to  soak  through  the  impermeable 
wax  covering,  soiling  all  the  linen  that  comes  in  contact  with  the 
patient.  As  the  secretions  are  sealed  up,  there  is  no  noticeable 
odor  about  the  patient,  which  was  a  disagreeable  factor  with  for- 
mer methods  of  treating  these  injuries. 

4.  Superficial  burns  heal  more  readily  under  the  wax  treatment 
than  with  any  other  method  with  which  I  am  familiar.  This 
is  due  to  but  one  fact:    Under  former  methods  of  application  of 


ABSTRACTS  OF  WAR  SURGERY  333 

solutions  and  oily  substances,  no  matter  what  their  kind,  the  granu- 
lations penetrated  the  meshes  of  the  dressing  in  contact  with  the 
wound  and  on  removal  at  redressings,  these  granulations  were  de- 
stroyed, regardless  of  the  care  with  which  the  dressing  was  done  or 
the  method  employed  in  the  removal  of  the  dressings  in  contact  with 
the  wound.  The  paraffin  film  method  does  not  adhere  to  the  in- 
jured area,  and  therefore  does  not  injure  the  granulation  tissue 
and  the  epithelium  that  is  attempting  to  cover  the  denuded  area. 
Early  in  the  course  of  the  burn,  if  it  is  an  extensive  one,  the  entire 
sealed  surface  of  the  dressing  will  be  filled  with  fluid  so  that  it  is 
merely  lifted  off.  Later,  as  the  wound  heals  the  secretion  dimin- 
ishes, and  the  granulations  begin  to  grow,  the  epithelial  islands  ap- 
pear as  white  points  at  the  side  of  hair  follicles,  and  from  these 
islands  the  epithelization  takes  place  rapidly  because  the  epithe- 
lium is  not  injured  in  the  dressings  and  redressings. 

5.  Deep  burns  do  not  repair  any  more  rapidly  under  this  method 
than  any  other  method.  There  is  no  difference  in  the  scars  of  burns 
treated  by  the  wax  method  and  any  other  method.  If  the  true  skin 
is  destroyed,  the  end-result  is  scar  tissue  or  an  ulcer.  If  scar  tissue 
replaces  the  destroyed  tissue,  it  performs  as  does  scar  tissue  that 
develops  under  any  and  all  forms  of  treatment,  and  as  scar  tissue 
has  performed  since  the  beginning  of  time.  We  have  tried  treat- 
ing two  sides  of  a  body  burned  to  about  the  same  degree,  with  the 
wax  method,  the  solution  method,  and  various  other  methods,  and 
have  been  unable  to  detect  any  difference  in  the  end-result,  as  to 
scar. 

6.  The  wax  method  is  much  more  comfortable  at  dressing  time 
than  any  other  method  with  which  I  am  familiar,  for  the  purely 
mechanical  reason  that  the  granulations  do  not  grow  through  it, 
and  it  is  lifted  off  painlessly.  To  those  who  have  to  do  with  burned 
men  this  means  a  great  deal.  The  pain  endured  by  the  patient  as 
the  dressings  were  removed  under  previous  methods  of  treating 
burns  left  an  unpleasant  impression  to  carry  with  one  on  the  day's 
rounds. 

7.  We  think  there  are  fewer  furuncles  on  our  burned  patients 
since  the  wax  has  been  used,  but  nephritis  is  quite  as  common. 

Disadvantages. — 1.  Some  patients  refused  to  be  treated  with  the 
wax  when  we  were  applying  the  warm  wax  directly  to  the  injured 
area,  because  of  the  pain.  These  complaints  are  no  longer  heard 
since  the  liquid  petrolatum  has  been  used  for  the  first  coat. 

2.  Owing  to  the  fact  that  this  method  has  received  so  much 


334  ABSTRACTS  OF  WAR  SURGERY 

favorable  comment  in  the  lay  press,  as  to  negligible  sears,  perfect 
comfort  on  application,  and  other  extravagant  statements,  the  man 
who  uses  it  for  the  first  time  will  probably  be  disappointed. 

3.  This  method  is  a  time  consumer;  it  requires  more  care  and 
patience  than  do  the  dressings  by  other  methods. 


ANESTHESIA  IN  WARFARE 

ANESTHESIA  IN  WARFARE.  —Report  to  the  Surgeon  General 
by  Paluel  J.  Flagg,  M.  D.,  Lecturer  on  Anesthesia,  Rockefeller 
Institute,  War  Demonstration  Hospital. 

Henri  Vignes,  in  a  paper  read  before  the  Societe  de  Pathologie 
Comparee,  insists  that  "It  is  very  important  to  have  specialists  in 
anesthesia  at  the  front,"  that  "anesthesia  must  not  be  made  an 
easy  berth  for  the  physician  who  is  sent  by  chance  to  a  military 
surgical  ambulance.  Each  surgeon  should  have  his  own  anesthetist, 
who  should  be  an  expert  in  his  specialty  and  should  be  conversant 
with  the  most  recent  advances." 

It  is  interesting  to  note  that  after  three  and  a  half  years  of  war 
the  British  Army  Medical  authorities  have  finally  established  a 
large  training  school  for  anesthetists.  This  school  is  located  at 
Buxton,  England.  Only  medical  officers  are  trained  in  this  special 
work. 

Communications  from  the  front  demonstrate  a  wide  divergence 
in  anesthetic  agents  and  methods  employed  by  the  Allied  forces 
and  suggest  deductions  and  conclusions  which  may  be  found  profit- 
able in  this  emergency. 

Anesthetic  Agents,  Methods  Employed  and  Difficulties  to  Be 
Overcome. — Ether  is  universally  used,  it  is  employed  as  a  terminal 
anesthetic  in  about  80  per  cent  of  all  cases.  It  is  argued  that  the 
ether  manufactured  in  Europe  is  irritating,  nonvolatile  and  ineffi- 
cient. These  characteristics  are  emphasized  when  used  with  an  open 
mask.  "It  is  not  much  better  than  our  wash  ether  at  home," 
writes  Guedel.  "It  is  difficult,  indeed,  to  put  a  patient  to  sleep 
with  it,  to  say  nothing  of  securing  a  quiet  state  of  anesthesia. 
From  the  coughing  and  the  great  quantities  of  mucus  secreted, 
it  would  seem  to  contain  more  sulphuric  acid  and  formalin  than 
anything  else.  Also  it  is  about  as  volatile  as  alcohol.  You  never 
get  any  frosting  on  the  mask.  Usually  a  patient  will  walk  right 
out  from  under  anesthesia  with  this  ether  in  spite  of  continuous 
administration,  and  a  clean  mask  becomes  soggy  and  useless  after 
about  ten  minutes.  Whether  or  not  this  ether  is  the  usual  European 
ether  I  am  not  certain,  but  from  many  inquiries  that  I  have  made 
I  am  inclined  to  believe  that  it  is. ' ' 

335 


336  ABSTRACTS  OF  WAR  SURGERY 

When  a  closed  method  is  used,  however,  these  difficulties  become 
less  apparent. 

The  Shipway  apparatus  is  quite  popular  with  the  British.  It 
has  proved  especially  useful  in  head  and  neck  work. 

Chloroform-ether  anesthesia  has  been  extensively  employed  by 

McCardie,  of  London.    After  numerous  experiments  it  was  found 

E    P 
that  the  proportion      '     ■  gave  the  greatest  satisfaction. 
Ib.l 

Bilhaut,  of  the  Hospital  International  de  Paris,  finds  chloroform 
easier  to  administer  than  ether  and  less  likely  than  ether  to  cause 
chilling  of  the  respiratory  tract  such  as  may  produce  pneumonia 
or  pulmonary  congestions.  In  812  important  operations  performed 
by  Bilhaut  there  were  no  unhappy  results  from  the  use  of  chloro- 
form.   The  reaction  on  the  liver  has  been  found  negligible. 

Geudel  states :  "I  have  come  to  the  point  that  with  all  my  anti- 
chloroform  prejudices  I  am  using  chloroform  in  all  cases  when  I 
can  not  get  American  ether." 

"From  my  point  of  view,"  writes  Corfield,  "patients  were  di- 
vided into  two  classes,  those  necessitating  a  short  anesthesia,  up  to 
ten  or  twelve  minutes,  who  were  given  nitrous  oxide,  and  those 
requiring  a  longer  period,  who  were  given  chloroform  and  ether. 
The  first  class  comprised  wounds  to  be  cut  out  and  dressed,  foreign 
bodies  removed  and  guillotine  amputations,  and  for  such  cases 
nitrous  oxide  was  used.  The  advantages  were  a  saving  of  both 
time  and  labor.  Time  was  saved  because  the  period  of  induction 
and  returning  consciousness  were  a  matter  of  seconds  rather  than 
minutes,  and  labor  was  saved  because  most  of  these  patients  could 
walk  back  to  their  own  wards,  either  by  themselves  or  by  the  help 
of  one  orderly,  whereas  chloroform  or  ether  would  have  meant 
that  every  case  would  be  a  stretcher  case.  For  prolonging  nitrous 
oxide  anesthesia  one  had  to  use  a  gas  and  air  mixture.  My  method 
was  to  get  them  deeply  under  and  then  push  back  the  air  valve  for 
a  quarter  to  a  third  of  an  inch  so  that  the  patient  would  get  suffi- 
cient oxygen  to  keep  him  from  asphyxiation.  Patients  varied  in 
the  amounts  they  required.  It  was,  one  might  say,  a  compromise 
between  color  and  consciousness;  with  too  much  air  they  became 
sensitive  to  pain,  and  with  too  little  air  they  became  cyanotic. ' ' 

The  importance  of  substituting  oxygen  for  the  air  which  is  em- 
ployed in  nitrous  oxide  air  anesthesia  is  rapidly  being  appreciated 
by  European  anesthetists.  The  resulting  gas  oxygen  anesthesia 
is  gradually  finding  its  proper  place  as  an  invaluable  anesthetic 
agent  in  military  surgery.  The  delay  in  this  movement  may  be 
explained  by  the  fact  that  the  majority  of  those  who  gave  an- 


ABSTRACTS  OF  WAR  SURGERY  337 

esthetics  at  the  beginning  of  the  war  were  not  all-around  experi- 
enced anesthetists.  Had  they  been  so  the  great  value  of  gas-oxygen 
anesthesia  in  selected  cases  would  have  been  well  known  to  them 
and  would  have  been  employed  at  the  start. 

The  English  were  the  first  to  introduce  the  use  of  gas-oxygen 
in  the  military  surgery  of  this  war.  The  simplest  methods  were 
used  with  success.  The  Clover  inhaler  and  other  closed  devices 
were  employed,  the  gases  being  fed  intermittently  and  rebreathing 
being  practiced.  The  advent  of  America  was  followed  by  a 
marked  impetus  in  gas-oxygen  anesthesia. 

Most  of  the  apparatus  sent  from  America  to  France  and  Eng- 
land for  the  administration  of  gas  and  oxygen  is  complicated  in 
structure,  designed  for  constant  flow  methods  and  intended  to 
be  as  nearly  as  possible  automatic  in  action.  These  machines  are 
for  the  most  part  accurately  and  painstakingly  made.  It  has  been 
attempted  in  the  construction  to  do  away,  if  possible,  with  the 
need  of  an  experienced  physician  anesthetist.  In  view  of  the 
shortage  of  anesthetists,  such  an  attempt  is  certainly  justifiable 
if  the  perfect  delivery  of  gases  were  the  solution  of  the  problem. 

M.  Boureau  recommends  ethyl  chloride  for  the  Divisional  Am- 
bulances and  Field  Hospitals  as  well  as  for  operations  in  the  Base 
Hospitals.  Induction  is  speedy  and  recovery  rapid  and  complete. 
The  patients  are  shocked,  more  or  less  tired  mentally  and  physic- 
ally from  continual  tension.  They  often  suffer  from  hemorrhage 
and  are  generally  depressed.  ' '  The  most  courageous  does  not  wish 
to  suffer  further  pain.  One  should  not  hesitate,  therefore,  to  put 
him  to  sleep  whenever  necessary. ' '  Ethyl  chloride  is  recommended 
as  the  anesthetic  of  choice.  It  is  well  borne  and  chosen  by  the 
patient,  where  ether  or  chloroform  have  been  previously  used. 
Boureau  has  made  use  of  ethyl  chloride  as  many  as  fifteen  times 
on  the  same  case  for  the  application  of  painful  dressings.  The 
recovery  from  the  anesthetic  is  proportional  to  the  size  of  the 
dose.  If  administered  less  than  ten  minutes  the  recovery  is  rapid. 
If  more  than  ten  minutes  the  period  of  recovery  may  extend  to  ten 
or  fifteen  minutes.  There  may  or  may  not  be  slight  vomiting  after 
the  recovery.  It  appears  to  be  especially  useful  in  pulmonary 
cases. 

•  B.  Desplas,  in  an  article  entitled,  Anesthesia  a  la  Stovaine  en 
Chirurgie  de  Guerre,  extols  spinal  anesthesia  as  easy  to  administer, 
rapid,  economical,  may  be  repeated,  good  in  emergency  work,  and 
does  not  demand  the  presence  of  a  specialist. 


338  ABSTRACTS  OF  WAR  SURGERY 

He  employs  stovaine  in  doses  of  5  cgm.  (ampoules  de  Billon), 
injected  between  the  fourth  and  fifth  lumbar  vertebrae. 

Instead  of  entertaining  his  patient  by  conversation  or  by  al- 
lowing him  to  smoke  or  view  the  operation,  he  recommends  abso- 
lute silence,  has  the  patient  blindfolded,  and  cotton  placed  in  his 
ears.  If  slight  pallor  or  nausea  appears  the  patient  is  instructed 
to  breathe  deeply  and  is  given  something  warm  to  drink. 

Intravenous  ether  anesthesia,  regional  intravenous  anesthesia, 
local  anesthesia  and  hypnotism  have  all  been  used  in  the  military 
surgery  of  the  present  war.  In  war  conditions  Podiapolsky  has 
found  that  the  men  responded  with  exceptional  facility  to  hypnosis ; 
he  found  only  about  2  per  cent  quite  refractory.  He  has  found  it 
useful  in  the  wounded  of  all  the  nationalities  that  he  has  encoun- 
tered. This  treatment  is  rather  for  the  sensory  crisis  of  psychic 
origin  than  for  anesthesia  for  major  operations. 

Henri  Vignes  points  out  in  an  interesting  manner  the  indica- 
tions for  general  anesthesia  as  opposed  to  local  anesthesia.  He 
believes  that  general  anesthesia  should  be  used:  In  bleeding  vas- 
cular regions,  where  dissections  are  difficult,  where  important  or- 
gans are  involved,  where  tendons  and  aponeuroses  cross  the  opera- 
tive field,  when  a  retractor  is  necessary,  involvement  of  the  crural 
or  popliteal  space,  in  wounds  of  the  leg  excluding  the  bulge  of  the 
calf,  in  wounds  of  the  bend  of  the  elbow,  lower  arm,  wrist  and 
especially  the  palm  of  the  hand,  in  deep  wounds  of  the  neck,  in- 
juries of  large  blood  vessels  and  periosteal  involvements,  for  pro- 
ducing local  anesthesia  he  employs  novocaine,  stovaine  and  cocaine. 

The  literature  which  is  at  our  disposal  brings  out  rather  vividly 
the  essential  difference  between  civil  and  military  anesthesia.  These 
differences  or  rather  difficulties,  which  must  be  met,  are  as  follows : 
the  lack  of  preliminary  preparation ;  the  unusual  and  urgent  need 
of  a  speedy  induction  and  a  rapid  recovery;  the  bulk  of  the  work 
to  be  disposed  of;  the  problem  of  securing  the  safest  and  most 
efficient  anesthesia  with  the  available  anesthetic  agents  and  ap- 
paratus. 

Lack  of  Preliminary  Preparation. — It  is  a  more  or  less  generally 
recognized  fact  that  unless  a  patient  is  properly  prepared  for 
operation  by  preliminary  catharsis  and  fasting  the  course  of  his 
anesthesia  will  not  run  smoothly.  We  fail  to  appreciate  this  fact 
in  our  routine  work  and  its  significance  is  only  apparent  when  an 
"immediate"  operation  is  undertaken. 

When  practically  all  operations  are  immediates,  as  is  the  case 
in  the  Zone  of  the  Advance  and  in  many  instances  in  the  Inter- 


ABSTRACTS  OP  WAR  SURGERY  339 

mediate  Zone,  we  are  constantly  confronted  by  this  situation.  "Not 
only  the  bowels  but  the  condition  of  the  bladder  requires  atten- 
tion. So  many  patients  voided  their  urine  while  under  nitrous 
oxide  gas,  a  bottle  was  given  them  as  a  matter  of  routine  immedi- 
ately before." 

As  might  be  expected  where  nitrous  oxide  alone  is  the  anesthetic, 
vomiting  is  infrequent.  "I  never  had  any  vomiting  after  this 
anesthetic  (N20)  and  I  dare  say  most  of  the  patients  had  a 
stomach  fairly  full  of  food,"  (Corfield).  On  the  other  hand,  the 
same  author  states,  "It  is  a  curious  thing  that  in  many  patients 
who  have  had  a  meal  just  before  they  were  wounded,  the  process 
of  digestion,  or  at  any  rate  the  stomach  movement,  is  totally  ar- 
rested and  they  will  often  vomit  food  ten  or  twelve  hours  after  they 
have  taken  it.  I  remember  one  patient  who  in  the  first  stage  of 
anesthesia,  started  to  vomit  violently  and  brought  up  three  bowl- 
fuls  of  bully  beef  and  biscuits.  By  the  time  he  had  finished  he 
was  fully  conscious  again,  and  I  found  out  from  him  that  he  had 
had  this  meal  twenty-eight  hours  before  and  that  he  had  been 
wounded  two  hours  after  it. " 

The  wounded  approaches  anesthesia  in  a  very  different  frame 
of  mind  from  the  ordinary  civil  patient.  He  has  been  for  hours 
on  intimate  terms  with  death.  He  has  seen  his  friend  of  yesterday 
spill  his  life's  blood  on  the  common  dust,  or  in  his  mind's  eye  he 
still  beholds  the  savage  bayonet  poised  above  his  breast.  To  such 
a  one  the  tinkle  of  instruments  implies  ultimate  recovery  and  the 
anesthetic  an  immediate  relief  from  urgent  pain.  Such  a  patient 
is  prone  to  yield  cheerfully  to  his  anesthetic  and  to  suffer  the 
minimum  of  excitement. 

The  routine  use  of  morphine  in  the  Dressing  Stations  and  the 
Field  Hospitals  if  occurring  shortly  before  operation  is  a  valuable 
aid  towards  securing  a  smooth  induction.  Soldiers  exposed  to  all 
sorts  of  weather  under  the  most  trying  conditions  become  victims 
of  bronchial  affections  which  render  them  particularly  irritable 
to  ether  vapor.  Continuous  smoking  increases  this  irritability, 
which  preliminary  morphine  allays  but  does  not  always  completely 
remove. 

The  injury  which  the  patient  has  experienced,  coupled  with  the 
subsequent  exposure  and  loss  of  blood,  tends  to  make  the  wounded 
an  easy  patient  to  anesthetize. 

The  accidental  and  peculiar  circumstances  which  preceded  an- 
esthesia administered  at  the  Field  Hospitals  and  ambulances,  as 
well  as  those  at  the  Casualty  Clearing  Stations,  are  such  as  to 


340  ABSTRACTS  OF  WAR  SURGERY 

counteract  the  need  of  the  usual  fast  and  catharsis,  reducing  or 
completely  eliminating  the  period  of  excitement,  shortening  the 
period  of  rigidity  and  hastening  the  onset  of  complete  relaxation. 

Anesthesia  administered  at  the  Base  Hospitals  and  elsewhere  in 
the  Zone  of  the  Interior  closely  resembles  the  anesthesia  ordinarily 
seen  in  civil  life.  Preliminary  preparation  may  be  painstaking 
and  deliberate  as  most  of  the  operations  done  here  are  planned  in 
advance. 

The  Unusual  and  Urgent  Need  of  a  Speedy  Induction  and  Rapid 
Recovery. — Where  hundreds  and  thousands  of  wounded  are  to  be 
briefly  treated  and  passed  on  for  further  observations,  it  is  es- 
sential that  each  patient  be  rendered  unconscious  and  recover  con- 
sciousness again  as  soon  as  possible.  A  slow  induction  takes  time 
which  should  be  used  for  operating,  otherwise  it  takes  longer  to 
induce  the  anesthesia  than  it  does  to  do  the  operation.  A  slow 
recovery  requires  the  presence  of  a  nurse  or  an  attendant  who 
might  be  useful  elsewhere;  it  also  prevents  rapid  evacuation  to 
the  Zone  of  the  Interior. 

In  order  to  meet  these  conditions  various  agents  and  methods 
have  been  employed  and  found  satisfactory.  Ethyl  chloride,  nitrous 
oxide,  nitrous  oxide  and  oxygen,  chloroform,  chloroform-ether  mix- 
tures and  ether  alone  have  been  used  for  general  anesthesia;  novo- 
caine,  cocaine,  stovaine  for  local  and  spinal  methods. 

For  general  anesthesia  gas  oxygen  is  certainly  the  anesthetic  of 
choice.  Its  limited  use  has  been  due  to  the  employment  of  com- 
plicated apparatus  designed  for  constant  flow  methods  instead  of 
simple  devices  for  use  with  an  intermittent  flow.  Marshall  ( Am. 
Jour.  Surg.,  i,  18)  makes  this  clear  when  he  says:  "The  ideal 
anesthetic  is  one  with  which  induction  is  rapid,  and  recovery  com- 
plete in  a  few  minutes  after  operation,  so  that  the  patient  is  in  a 
fit  condition  for  early  evacuation  by  the  ambulance  train.  Ap- 
paratus is  subjected  to  much  wear  and  tear,  so  it  should  not  be 
complicated  or  delicate.  Of  the  anesthetics  I  have  used  gas  and 
oxygen  meets  these  requirements  best.  Its  only  drawbacks  are 
that  the  apparatus  is  somewhat  cumbersome  and  the  materials 
costly."  Apparatus  for  the  administration  of  gas  oxygen  anes- 
thesia by  the  method  of  intermittent  flow,  is  not  cumbersome  and 
the  volume  of  gas  consumed  is  so  small  that  the  method  is  not 
costly. 

Ethyl  chloride  resembles  gas-oxygen  in  its  speed  of  induction 
and  its  rapid  recovery.  It  appears  fairly  safe  in  experienced 
hands.     M.  Boureau  (Presse  medical,  21,  May  17)  recommends  it 


ABSTRACTS  OP  WAR  SURGERY  341 

for  its  nontoxic  qualities,  its  rapid  elimination  and  the  ease  with 
which  it  is  accepted  by  the  patient.  It  is  especially  useful  as  a 
first-aid  anesthetic ;  i.  e.,  ligation  of  blood  vessels,  removal  of  large 
superficial  foreign  bodies,  etc.  Nothing  could  be  more  simple  than 
the  paraphernalia  required,  for  a  handkerchief  is  all  that  is  neces- 
sary. 

The  Bulk  of  the  Work  to  Be  Disposed  of. — Operative  activity  in 
the  Zone  of  Advance  and  in  the  Intermediate  Zone  depends  directly 
upon  military  activity  in  the  particular  zone  under  consideration. 
The  surgery  which  is  done  in  the  Base  Hospitals  in  the  Zone  of  the 
Interior,  drawing  as  it  does  its  wounded  from  a  wide  territory,  is 
of  a  more  leisurely,  more  constant,  and  less  acute  nature. 

Major  Kellog  Speed  describes  the  methods  in  the  average  Casualty 
Clearing  Station  as  follows :  "In  addition  to  administrative  offi- 
cers, etc.,  there  are  assigned  to  each  Casualty  Clearing  Station 
surgical  teams  composed  of  picked  men  of  surgical  ability,  each 
supplied  with  his  own  anesthetist,  operating  nurse  and  orderly. 
These  teams  divide  the  major  and  the  minor  surgical  patients  in 
rotation  as  fast  as  they  are  able  to  finish  each  operation.  Team 
work  is  divided  thus,  each  team  works  for  eight  hours  a  day  except 
during  rush  times,  when  they  are  expected  to  do  sixteen  hours' 
duty.  Three  teams  are  on  duty  from  9  :00  a.  m.  to  5  :00  p.  m.  in  the 
major  theater,  using  five  or  six  operating  tables;  two  teams  work 
from  5 :00  p.  m.  to  1 :00  a.  m.,  and  one  team  from  1 :00  a.  m.  to  9  :00 
a.  m.,  under  ordinary  conditions.  The  work  is  continuous  as  long 
as  the  hospital  is  taking  in.  Teams  cease  to  take  on  patients  one-half 
hour  before  the  expiration  of  their  time  so  that  their  table  may  be 
cleaned  up  and  prepared  for  the  next  group. 

"The  major  operating  theater  is  centrally  located.  The  minor 
theater  is  near  the  dressing  tent.  All  are  electrically  lighted.  The 
arrangement  of  five  or  six  tables  in  the  major  theater  permits  the 
anesthetist  to  move  from  patient  to  patient  in  advance  of  the 
operator  while  dressings  and  splints  are  being  applied  or  the  opera- 
tion is  being  finished.  The  operating  nurse  assists  the  surgeon, 
the  orderly  brings  in  the  supplies,  helps  with  the  dressings  and 
cleans  up  the  table.  There  is  complete  independence  for  each 
team. ' ' 

The  necessarily  large  amount  of  work  to  be  done  in  a  short  time 
calls  for  skilful  and  speedy  anesthesia.  Gwathmey  writes  as  fol- 
lows: "Nitrous  oxide-oxygen  and  ether  is  the  only  anesthetic  for 
this  kind  of  work,  as  speed  is  the  only  desideratum.    I  have  given 


342  ABSTRACTS  OF  WAR  SURGERY 

as  many  as  thirty-four  anesthetics  in  one  day — something  which 
would  be  impossible  with  chloroform  or  ether. ' ' 

The  Problem  of  Securing  the  Safest  and  Most  Efficient  Anes- 
thesia With  the  Available  Anesthetic  Agents  and  Apparatus. — This 
problem  is  one  of  the  great  difficulties  of  military  anesthesia.  Spe- 
cial supplies  soon  become  exhausted  and  are  difficult,  if  not  im- 
possible, to  replace.  Intricate  apparatus  often  can  not  be  re- 
paired on  the  spot  and  becomes  worse  than  useless.  The  ability 
to  improvise  apparatus  is  essential.  Improvised  apparatus  can 
be  safely  used  only  by  an  experienced  administrator,  for  experience 
must  supply  the  elements  of  safety  which  the  apparatus  lacks. 
The  Field  Hospital,  the  Divisional  Ambulance  and  the  Casualty 
Clearing  Station  is  no  place  to  begin  one's  experience  as  an  anes- 
thetist. The  anesthesia  administered  here  must  be  expert  from 
every  point  of  view.  Unless  this  is  so  an  attempt  to  make  speed 
will  result  in  a  stormy  induction,  and  uneven  maintenance  under 
poor  control  and  a  delayed  recovery.  One  must  know  by  ex- 
perience the  limits  of  safety  which  the  patient  will  tolerate.  The 
experienced  man  will  not  be  carried  away  by  the  allurements  of  a 
new  agent  or  technic  which  is  brought  before  his  attention,  as  he 
will  already  have  experienced  fads  and  seen  their  early  demise. 
The  experienced  man  will  be  conservative,  and  for  this  reason  safe. 
On  the  other  hand,  he  will  be  so  familiar  Math  the  various  phe- 
nomena which  normally  appear  with  the  unconsciousness  of  an- 
esthesia that  the  question  of  apparatus  to  bring  about  this  state 
will  be  of  secondary  consideration.  He  will  appreciate  the  value 
of  preliminary  medication  and  he  will  be  in  a  position  to  diagnose 
preliminary  medication  which  has  not  been  reported  and  which 
influences  the  course  of  the  anesthesia.  The  military  anesthetist 
should  not  only  know  the  best  methods  which  are  available  for  in- 
sufflation anesthesia,  but  he  should  be  able  to  improvise  inhalation 
methods  to  take  their  place.  He  should  be  prepared  to  give  good 
gas  oxygen  anesthesia  without  the  use  of  percentage  devices  de- 
pendent upon  complicated  reducing  valves  and  heating  attach- 
ments. 

The  difficulty,  then,  of  accomplishing  satisfactory  anesthesia  with 
limited  apparatus  implies  the  need  of  a  trained  anesthetist.  As 
there  is  little  likelihood  of  a  sufficient  number  of  trained  anesthe- 
tists being  found  in  the  enlisted  personnel  to  supply  the  demands 
of  the  army  and  navy  the  government  is  confronted  with  the 
problem  of  training  anesthetists  for  the  various  branches  of  its 
service. 


ABSTRACTS  OF  WAR  SURGERY  343 

Deductions  and  Conclusions. — The  most  striking  fact  brought 
out  by  the  increasing  number  of  articles  dealing  with  "the  anes- 
thesia at  the  front"  is  the  complete  diversity  of  views  as  to  the 
best  anesthetic  agent  and  technic  of  administration  to  be  used  as 
a  routine  under  given  conditions.  Straight  ether  by  the  open  and 
semiopen  method,  chloroform,  ether  mixtures,  ethyl  chloride, 
nitrous  oxide-oxygen,  spinal  anesthesia,  and  even  hypnotism,  as 
we  have  seen,  each  has  its  earnest  advocate,  who  uses  his  method 
largely  to  the  exclusion  of  others. 

One  might  conclude  from  this  condition  of  affairs  that  one 
agent  and  method  is  about  as  good  as  another,  that  the  apparent 
success  of  all  methods  is  due  to  a  keen  specialization  of  the  par- 
ticular method  in  question,  or  that  the  agent  and  the  method  em- 
ployed is  merely  the  result  of  accident,  nothing  else  having  been 
available. 

The  first  consideration,  that  one  anesthetic  agent  and  method  is 
as  good  as  another  will  find  credence  only  with  those  who  are  un- 
acquainted with  the  subject.  For  the  ability  to  choose  the  anes- 
thetic and  its  method  of  administration  is  the  mark  which  dis- 
tinguishes the  physician  anesthetist  from  the  mere  lay  technician 
or  so-called  nurse  anesthetist. 

The  second  consideration,  that  the  apparent  success  of  all  meth- 
ods is  due  to  specialization  of  the  method  in  question,  is  certainly 
true  to  a  considerable  degree.  Practice  makes  perfect  here  as  in 
any  other  division  of  labor.  By  constant  application  anyone  of 
ordinary  manual  dexterity  can  give  an  entirely  satisfactory  anes- 
thesia with  ether,  chloroform,  ethyl  chloride,  or  even  with  gas  and 
oxygen.  If  this  were  the  end  of  the  matter  no  harm  would  be 
done;  the  difficulty  lies  in  these  administrators  heralding  their 
work  as  a  discovery  and  inviting  the  uninitiated  to  follow  in  their 
steps.  The  worth  of  any  anesthetic  agent  can  be  determined  only 
by  the  aggregate  experience  of  many  workers.  It  is  only  in  this 
fashion  that  we  may  anticipate  and  guard  against  fatalities  in  the 
work  of  the  average  anesthetist.  It  is,  therefore,  not  fair  to  con- 
clude that  specialization  in  the  use  of  a  single  agent  will  control 
the  safety  of  that  particular  drug,  that  experience  alone  is  all  that 
is  essential  to  make  a  drug  safe. 

The  third  consideration,  that  the  agent  and  the  method  em- 
ployed is  merely  the  result  of  accident,  nothing  else  having  been 
available,  may  be  true  where  there  is  a  constantly  shifting  per- 
sonnel, as  is  likely  to  occur  in  the  Field  Hospital  and  the  Casualty 


344  ABSTRACTS  OF  WAR  SURGERY 

Clearing  Station.  In  the  Base  Hospitals,  on  the  contrary,  the 
personnel  is  more  or  less  fixed  and  the  selection  of  the  anesthetic 
may  be  painstaking  and  deliberate.  The  literature  which  has 
appeared  has  been  of  such  a  character  as  to  emphasize  the  fact 
that  the  worker  at  the  Base  Hospital  has  had  not  only  the  time 
but  the  inclination  to  work  out  the  problem  of  anesthesia  in  his 
particular  case. 

The  diversity  of  opinion,  then,  which  shows  itself  in  the  litera- 
ture is  quite  natural  and  interesting.  Surgical  methods  and  tech- 
nic  changes  with  war  conditions. 

Anesthesia,  when  accommodated  to  the  difficulties  mentioned 
in  the  first  part  of  this  article,  namely,  the  need  of  a  rapid  induc- 
tion and  recovery  in  a  large  number  of  poorly-prepared  patients, 
often  with  improvised  apparatus,  remains  essentially  the  same  as 
it  was  before  the  war.  The  underlying  principles  for  inducing 
and  maintaining  anesthesia  are  the  same,  and  the  accepted  methods 
of  securing  rapid  and  complete  recovery  are  identical.  The  need 
of  anesthesia  in  wounded  cases,  as  pointed  out  by  M.  H.  Vignes 
(Presse  medical,  Dec.  4,  1916),  is  even  greater  than  in  times  of 
peace.  "It  is  absolutely  necessary  to  protect  patients  from  pain. 
Anesthesia  alone  places  the  patient  in  the  best  condition  and  al- 
lows the  performance  of  good  surgery,  and,  of  even  greater  im- 
portance, it  prevents  shock  incidental  to  surgical  manipulation, 
which  has  been  added  to  that  of  trauma.  One  can  die  of  pain.  It 
is  essential  to  be  as  economical  in  the  loss  of  nervous  energy  as 
in  the  loss  of  blood.  The  ambulances  should,  therefore,  have 
trained  anesthetists,  and  perfected  appliances  should  be  carried 
to  the  front." 

In  the  light  of  the  facts  which  have  been  considered,  it  would 
seem  just  to  assume  the  following  conclusions : 

1.  That  in  the  Zone  of  Advance  and  in  the  Intermediate  Zone 
the  anesthetic  indicated  for  incomplete  anesthesia  is  gas  and 
oxygen,  administered  in  the  simplest  manner;  namely,  by  the 
method  of  intermittent  flow  with  rebreathing.  Complete  anesthesia 
to  be  brought  about  and  maintained  by  ether  given  with  a  closed 
method,  recovery  to  be  ushered  in  and  completed  by  a  return  to  gas 
and  oxygen. 

When  gas  and  oxygen  is  not  available  a  chloroform,  ether,  ethyl 
chloride  or  chloroform  anesthesia,  may  be  employed  for  incomplete 
anesthesia,  which  may  be  made  complete  and  maintained  by  ether 
given  by  a  semiopen  or  closed  method. 

2.  That  spinal,  intravenous,  regional  or  morphine  hyocine  anes- 


ABSTRACTS  OF  WAR  SURGERY  345 

thesia,  per  se,  be  reserved  as  methods  of  expediency  to  be  used 
by  an  experienced  administrator. 

3.  That  in  the  Zone  of  Advance  and  in  the  Intermediate  Zone 
inhalation  methods  be  the  methods  of  choice.  Intrapharyngeal 
and  intratracheal  inhalation  anesthesia  for  head  and  neck  work 
by  the  tin-can  method,  to  be  used  in  preference  to  complicated 
insufflation  methods. 

On  the  other  hand,  in  the  Zone  of  the  Interior,  the  Base  Hos- 
pitals should  have  the  best  and  most  complete  equipment.  Gas- 
oxygen  by  constant  flow  methods  may  here  be  used  if  desired. 
Insufflation  anesthesia  by  the  Connell  Anesthetometer  should 
be  the  method  of  choice.  At  the  Base  Hospital  arrangements  should 
be  made  to  instruct  as  well  as  to  anesthetize.  The  most  complete 
ante-  and  post-  operative  treatment  may  here  be  carried  out,  with 
every  assurance  of  success. 

ANESTHETICS  AT  A  CASUALTY  CLEARING  STATION.— 

G.  Marshall.    Proc.  Boy.  Med.  and  Ghir.  Soc,  London,  1917, 
x,  Sect.  Anesth.,  p.  17. 

Gas  and  oxygen  anesthesia  meets  the  requirements  best  in  slightly 
injured  cases.  Its  only  drawbacks  are  that  the  apparatus  is  some- 
what cumbersome  and  the  materials  costly.  Local  anesthesia  can  be 
employed  only  in  a  small  number  of  cases  on  account  of  the  multi- 
plicity of  wounds  and  their  lacerated  and  soiled  condition.  Ether 
remains  the  most  generally  used  anesthetic.  The  great  majority 
of  slight  cases  are  anesthetized  by  Shipway's  warm  vapor  method. 
For  induction  the  mixed  vapors  of  ether  and  chloroform  are  used ; 
the  patient  is  free  from  struggling  so  that  it  is  seldom  necessary 
for  an  assistant  to  stand  by  the  patient.  It  is  rapid ;  in  a  hundred 
cases  which  were  timed,  induction  was  invariably  complete  in  five 
minutes.  Anesthesia  is  maintained  with  ether  alone.  There  is  an 
absence  of  secretion,  and  atropine  is  not  given  unless  the  patient 
has  signs  of  bronchitis.  Consciousness  is  regained  quickly  and 
vomiting  has  occurred  in  only  26  per  cent  of  all  cases,  including 
abdominal  cases.  Since  the  warm  vapor  method  was  introduced, 
the  drop  bottle  has  passed  out  of  use.  Compared  with  the  open 
method  there  is  a  saving  of  at  least  60  per  cent  of  ether.  There  is 
much  less  diffusion  of  the  anesthetic  into  the  atmosphere  of  the 
theater.  This  is  important  to  those  working  in  it  at  times  of  sus- 
tained pressure. 

It  has  been  urged  that  spinal  anesthesia  would  be  of  great  value 


346  ABSTRACTS  OF  WAR  SURGERY 

in  military  surgery.  For  men  wounded  in  the  lower  extremities, 
it  is  a  convenient  and  satisfactory  method  at  a  base  hospital; 
cases  of  profound  collapse  do  not  occur.  The  same  good  results 
were  obtained  at  a  clearing  station  in  all  patients  who  had  been 
wounded  not  less  that  forty  hours  before  operation.  It  is  to  the 
man  whose  wounds  are  less  than  forty  hours  old  and  who  has  lost 
blood  that  spinal  anesthesia  is  dangerous.  Of  the  recently  wounded 
patients  all  do  not  collapse  under  spinal  anesthesia.  It  is  impor- 
tant that  one  should  be  able  to  recognize  beforehand  which  cases 
will  tolerate  this  procedure.  Is  there  any  physical  sign  which  will 
prove  a  reliable  guide  ?  The  appearance  of  the  patient  is  of  little 
assistance,  the  pulse-rate  and  blood-pressure  do  not  help  at  all. 
A  valuable  indication  is  obtained  by  determining  the  concentra- 
tion of  the  blood.  The  method  the  author  employs  is  to  estimate 
the  percentage  of  hemoglobin  in  the  patient's  blood  by  means  of  a 
Galdane  hemoglobinometer.  If  a  recently  wounded  man  has  a 
hemoglobin  percentage  of  over  100,  it  is  safe  to  administer  stovaine 
intrathecally.  If  the  reading  is  below  100  per  cent,  he  will  al- 
most certainly  show  a  serious  fall  of  blood  pressure  and  symptoms 
of  collapse. 

Subcutaneous  injection  of  strychnine  appears  to  be  without 
value,  both  as  a  preliminary  measure  to  prevent  collapse  and  sub- 
sequently in  its  treatment.  Intramuscular  injection  of  pituitrin 
proved  useless  in  combating  the  fall  of  blood-pressure.  Intraven- 
ous saline  caused  temporary  improvement  in  the  one  case  in  which 
it  was  tried  but  the  blood-pressure  fell  again  after  one  and  a  half 
hours  and  the  patient  died.  This  last  case  was  a  man  with  a  pene- 
trating wound  of  the  abdomen.  The  author's  experience  with 
spinal  anesthesia  for  these  cases  has  been  limited  and  unfortunate. 
Three  men  with  penetrating  wounds  of  the  abdomen  were  each 
given  0.67  gm.  of  stovaine.  In  each  case  the  injection  was  fol- 
lowed by  a  great  fall  of  blood  pressure  and  death  within  a  few 
hours. 

Spinal  anesthesia  is  contraindicated  in  shock.  Incomparably 
good  results  are  obtained  with  gas  and  oxygen  and  no  ether  anes- 
thetic should  be  used  for  this  type  of  case.  The  anesthesia  may  be 
so  light  that  the  patient  will  move  when  nerves  are  resected. 

The  opinion  is  now  general  that  chloroform  is  a  bad  anesthetic 
for  head  cases.  Operation  may  be  performed  under  local  anesthe- 
sia; all  tissues  of  the  scalp  are  infiltrated  in  a  circle  widely  sur- 
rounding the  site  of  incision  A  0.2  per  cent  solution  of  novocaine 
with  adrenalin  is  generally  used.    The  forcible  cutting  of  bone  is 


ABSTRACTS  OF  WAR  SURGERY  347 

disturbing  to  the  patient,  so  that  where  mentality  is  unimpaired 
general  anesthesia  is  preferable.  Warm  ether  vapor  is  exceedingly 
satisfactory. 

It  is  in  the  group  of  cases  with  abdominal  wounds  that  the  warm 
vapor  method  has  shown  to  the  full  its  striking  advantages.  The 
quiet  induction  may  save  much  loss  of  blood  from  wounded  ves- 
sels in  the  peritoneal  cavity.  The  easy  breathing  and  diminished 
heat  loss  leave  the  patient  in  a  remarkably  good  condition  at  the 
end  of  a  long  operation.  "With  open  ether  34  per  cent  of  the  ab- 
dominal cases  had  bronchitis  after  operation.  With  warm  ether 
vapor  the  percentage  has  dropped  to  14.7.  Apart  from  copious 
hemorrhage,  there  is  one  other  procedure  which  causes  a  rapid 
fall  of  blood  pressure  during  abdominal  operations.  This  is  turning 
the  patient  on  his  side.  The  effect  is  produced  only  if  the  patient 
has  been  under  the  anesthetic  for  a  considerable  time  before  being 
turned.  For  abdominal  cases  oxygen  with  the  ether  vapor  is  given. 
No  atropine  is  administered  before  operation  as  there  is  no  ad- 
vantage in  giving  it.  Ether  gives  better  results  than  chloroform 
in  these  cases.  With  chloroform  the  blood  pressure  falls  steadily 
and,  if  operation  be  prolonged,  the  patient  may  die  before  the  ab- 
domen is  closed,  or  shortly  after. 

Hypertonic  saline  given  intravenously  raises  the  blood  pressure, 
slows  the  pulse-rate  and  dilutes  the  blood  for  a  longer  period 
than  does  the  normal  solution. 


TRENCH-FOOT 

TRENCH-FOOT.— H.  M.  Frost.     Boston  Med.  and  Surg.  Jour., 
1917,  clxxvi,  p.  301. 

The  author  gives  a  very  interesting  and  complete  account  of 
trench-foot.  The  factors  which  tend  to  produce  it  are:  (1)  cold — 
not  enough  to  freeze  of  itself  but  enough  to  reduce  the  resistance 
of  the  tissues  through  chilling;  (2)  wet — accentuating  the  chilling 
effects  of  the  cold  and  interfering  with  the  circulation  by  causing 
shoes  and  puttees  to  shrink;  (3)  inactivity — often  in  cramped  po- 
sitions, conducive  to  a  sluggish  circulation,  not  only  from  lack  of 
exercise  but  from  constriction  of  vessels  in  the  popliteal  space. 
Officers  are  much  less  affected  with  trench-foot  than  privates. 

Trench-foot  occurs  during  the  winter  months,  roughly  December 
to  March.  During  the  winter  months  in  1914-15  trench-foot  oc- 
curred in  17  per  cent  of  the  admissions  at  the  American  "Women's 
"War  Hospital  at  Paignton.  The  winter  of  1915-16  showed,  how- 
ever, that  this  number  had  decreased  to  nearly  one-third. 

The  symptoms  occur  after  the  soldiers  have  been  on  duty  in  the 
trenches  for  from  a  few  hours  to  several  days  soaked  with  cold 
water  up  to  the  knees  or  hips.  First  comes  numbness  and  cold, 
followed  by  pain  and  tenderness  which  makes  walking  difficult. 
Pain  may  be  burning  or  tingling  and  is  most  marked  at  the  points 
of  greatest  pressure,  the  heel  and  the  ball  of  the  foot;  often  it  is 
rheumatic,  involving  the  toes  and  ankles  and  extending  up  to  the 
knee  and  thigh  muscles. 

Clinically  in  the  simplest  type  there  is  a  discoloration,  varying 
from  a  hyperemia  to  a  dark  red  or  a  purple  hue,  usually  confined  to 
areas  where  greatest  pressure  is  exerted  by  the  shoe.  Anesthesia 
to  the  touch  and  pin-point  confined  to  the  areas  of  discoloration  is 
common  in  the  toes.  Hyperesthesia  generally  occurs  in  a  small 
zone  just  outside  the  anesthetic  area.  More  severe  cases  may  be 
pale  and  the  hyperesthesia  more  marked  with  severe  pain  on  ex- 
posure to  heat  or  motion  of  the  joints.  Still  severer  cases  are  ac- 
companied by  edema  and  bleb  formation  and  great  pain  with  both 
anesthesia  and  hyperesthesia.  In  these  cases  gangrene  at  times 
supervenes  at  those  areas  where  the  pressure  has  been  most 
marked. 

348 


ABSTRACTS  OF  WAR  SURGERY  349 

Treatment  consists  of  elevation  of  feet,  protection  from  heat, 
massage  with  oil,  and  sedatives.  The  greater  part  of  the  edema 
subsides  in  two  to  three  days.  The  simplest  cases  recover  in  about 
two  weeks,  the  average  in  three  weeks,  and  the  most  severe  in 
from  five  to  seven  weeks.  Where  gangrene  has  occurred  amputa- 
tion of  varying  degrees  is  necessary,  and  this  means  being  in- 
valided out  of  service. 

Prevention  is  a  matter  of  great  importance.  The  measure  of 
greatest  benefit  seems  to  be  a  shorter  period  of  duty  in  the  trenches 
with  more  frequent  relief.  Such  a  thing  as  keeping  the  trenches 
dry  is  practically  impossible  in  the  first  line,  in  the  winter  time. 
Long  waterproof  boots  which  impede  the  activity  of  the  soldier 
are  objectionable;  frequent  application  of  oil  helps  somewhat,  but 
the  best  method  is  to  have  sufficient  reserve  to  permit  frequent 
relief  from  trench  duty. 

TRENCH-FOOT.— Rev.  of  War  Surg,  and  Med.,  September,  1918, 
ii,  No.  7. 

1.  Trench  foot  is  a  pathological  condition  provoked  by  moist 
cold  and  complicated  as  a  rule  by  secondary  infection. 

2.  The  disorder  presents  four  stages,  as  follows:  (1)  Painful 
anesthesia;  (2)  edema;  (3)  phlyctenules;  (4)  sloughing.  Three 
clinical  forms  may  be  described — (a)  slight  (85  to  90  per  cent 
of  the  cases),  characterized  by  painful  anesthesia,  edema,  and 
redness;  (b)  moderate  (13  to  14  per  cent),  characterized  by 
phlyctenules  and  limited  sloughs;  (c)  severe  (1  per  cent  on  an 
average),  characterized  by  extension  of  sloughing  and  the  appear- 
ance of  septicemic  complication.  This  form  may  produce  serious 
mutilation  or  death. 

3.  Trench-foot,  especially  the  more  serious  forms,  is  not  infre- 
quently complicated  by  tetanous  or  gas  gangrene,  and  relapses 
and  recurrences  may  take  place.  Trench  foot  occurs  almost  ex- 
clusively in  soldiers  who  live  in  the  trenches,  more  particularly 
in  certain  trenches.  Soldiers  coming  from  hot  countries,  dark- 
skinned  races  particularly,  are  more  frequently  attacked  than 
Europeans.  (In  Italy  soldiers  from  the  south  have  suffered  more 
often  than  soldiers  from  the  north.)  Youth,  hyperidrosis,  and  a 
previous  attack  are  predisposing  causes. 

4.  Blood  stasis  due  to  prolonged  standing,  to  long  immobility, 
and  to  a  bad  attitude  (stooping),  compression  of  the  leg  and  inter- 
ference with  the  venous  circulation,  particularly  by  puttees,  and 


350  ABSTRACTS   OF   WAR   SURGERY 

more  especially  remaining  long  in  cold  and  damp  (muddy  and 
flooded  ditches  and  shell  holes),  are  the  principal  causes  of  trench- 
foot. 

5.  Trench-foot  may  be  confused  with  true  frost-bite  and  with 
chilbains.  True  frost-bite  is  characterized  by  sudden  massive  mor- 
tification of  a  part  of  a  limb  (the  front  of  the  foot,  the  whole 
foot,  etc.)  ;  trench  foot,  on  the  contrary,  is  characterized  by  lim- 
ited destruction  (gangrenous  patches  on  the  dorsum  of  the  foot, 
the  sole  or  the  toes)  and  by  progressive  invasion  of  the  tissues 
of  the  foot.  Frost-bite  is  met  with  in  severe  dry  cold,  especially 
in  mountainous  regions.  Trench  foot  occurs  only  in  damp  weather 
and  at  low  altitudes  (valleys,  plains)  ;  it  disappears  in  frost.  Chil- 
blains are  characterized — at  any  rate  in  their  early  stage — by  very 
severe  itching,  whereas  those  forms  of  trench  foot — that  is  to  say, 
the  slight  forms — which  are  liable  to  be  confused  with  chilblains, 
produce  painful  anesthesia  without  any  itching.  It  has  to  be  ad- 
mitted, however,  that  sometimes  the  diagnosis  between  ulcerated 
chilblains  and  the  ulcerated  phlyctenules  of  trench-foot  may  be 
doubtful. 

6.  The  treatment  of  trench-foot  is  preventive  and  curative.  Pre- 
ventive treatment  energetically  applied  and  supervised  may  be 
followed  by  the  disappearance  of  cases  of  trench-foot,  or  may  at 
least  render  them  very  rare.  The  treatment  includes  (a)  collective 
measures — hygiene  and  draining  of  the  trenches,  gratings,  trench 
boots,  dry  warmed  shelters,  with,  if  necessary,  frequent  reliefs; 
and  (b)  individual  preventive  precautions  taken  daily  (drying, 
cleansing  and  massage  of  the  feet,  change  of  socks  in  the  shelters, 
supervision  of  the  puttees  and  of  everything  that  can  cause  com- 
pression of  the  lower  limbs).  Belgian  medical  officers  attribute 
the  extreme  rarity  of  cases  of  trench-foot  in  their  army  to  the 
disuse  of  puttees.  The  curative  treatment  of  trench  foot  includes 
the  following  measures:  (a)  Slight  cases;  a  warm  foot  bath  should 
be  taken  every  two  or  three  days  and  the  feet  washed  with  boric 
camphor  soap.  A  large  moist  boric  camphor  dressing  should  be 
applied  to  the  foot  every  day.  (b)  Severe  cases;  when  phlyc- 
tenules only  are  present  they  should  be  opened  and  touched  with 
camphorated  ether,  and  a  moist  boric  camphor  dressing  applied. 
If  there  are  sloughs  the  same  treatment  should  be  persistently 
applied.  Sloughs  should  not  be  removed  with  the  knife;  they 
should  only  be  scarified,  without  causing  bleeding,  so  that  the 
drugs  used  may  act  on  the  subjacent  tissues.  Spontaneous  sep- 
aration  must   be   awaited,   and   complications   carefully   watched 


ABSTRACTS  OF  WAR  SURGERY  351 

and  thoroughly  treated  surgically  and  fully  at  their  onset.  The 
principle  by  which  operation  ought  to  be  guided  is  that  it  should  be 
late  and  confined  to  the  rectification  of  stumps  which  are  defective 
from  a  functional  point  of  view.  Amputation  should  be  performed 
only  in  cases  in  which  the  surgeon's  hand  is  forced  by  serious 
general  complications.  In  every  case  preventive  anti-tetanic  treat- 
ment should  be  used  (injection  of  antitetanic  serum  repeated  every 
week  until  the  wound  is  cicatrized). 


SHOCK 

SHOCK  AS  SEEN  AT  THE  FRONT.— E.  Archibald,  and  J.  W. 
Maclean. — Tr.  Am.  Surg.  Assn.,  Boston,  1917,  June. 

An  analysis  is  given  of  40  cases  of  shock  due  chiefly  to  wounds 
of  the  abdomen  and  high  explosive  wounds  of  the  extremities  as 
seen  at  a  casualty  clearing  station,  situated  five  to  seven  miles 
behind  the  trenches. 

Attention  is  called  particularly  to  the  subnormal  temperature 
found  in  bad  cases  of  shock,  in  which  the  ordinary  clinical  ther- 
mometer was  often  found  to  be  insufficient,  that  is,  that  the  patient's 
temperature  was  obviously  below  92°.  This  suggests  the  desirabil- 
ity of  a  new  form  of  clinical  thermometer  with  a  register  running 
from  80°  F.  up.  Attention  was  called  to  the  observations  of  Gor- 
don Holmes,  who  found  in  cases  of  injury  of  the  cord  at  the  sixth 
to  eighth  cervical  segments  a  temperature  of  80°,  which  was  com- 
patable  with  life  for  several  days. 

An  analysis  of  the  author's  cases  shows  the  profound  effect  of 
fatigue,  cold,  and  exposure  to  wet,  in  the  production  and  aggrava- 
tion of  shock.  From  numerous  blood  pressure  observations,  the 
general  rule  might  be  deduced  that  in  the  presence  of  a  pressure 
of  below  75  mm.  recovery  was  the  exception. 

Of  seventeen  cases  with  a  blood  pressure  of  below  75  mm.  only 
three  rallied  from  shock,  and  they  died  in  two  to  three  days  from 
gas  gangrene. 

While  hemorrhage,  even  of  moderate  degree,  is  apt  to  aggravate 
shock,  in  the  authors'  opinion  there  is  a  fundamental  difference 
between  the  two ;  and  the  recent  view  of  Mann,  Gatch,  and  others, 
that  the  two  were  essentially  of  like  nature,  was  combated.  In 
severe  shock  there  is  apathy  and  cyanosis,  as  opposed  to  restless- 
ness and  blanching  in  hemorrhage ;  another  striking  difference  lay 
in  the  effect  of  intravenous  salt,  or  of  blood  transfusion  helpful  in 
hemorrhage,  useless  in  shock. 

In  treatment,  Hogan's  gelatine  solution  restored  blood  pressure 
and  held  it  up  longer  than  did  intervenous  saline;  and  both  were 
of  some  benefit  in  the  milder  cases  of  shock  combined  with  hemor- 

352 


ABSTRACTS  OF  WAR  SURGERY  353 

rhage.  In  bad  cases,  neither  was  of  permanent  benefit.  Trans- 
fusion was  disappointing.  It  had  no  more  permanent  effect  than 
the  gelatine  solution.  Pituitrin  was  of  some  value  in  moderate 
shock,  but  not  in  serious  shock.    Amyl  nitrate  was  of  no  value. 

In  blood-pressure  readings,  the  systolic  pressure  is  not  so  im- 
portant as  the  diastolic.  Systolic  may  occasionally  be  up  near  100, 
and  diastolic  20  to  40 ;  this  spells  shock.  If  the  intravenous  saline 
raises  a  low  systolic,  but  fails  to  raise  the  diastolic,  shock  is  still 
present  and  unrelieved  and  the  patient  will  die.  If  the  sharp  click 
of  the  systolic  is  weak  or  distant  throughout,  there  is  danger.  If  the 
systolic  sound  is  first  heard  only  during  expiration,  and  becomes 
continuous  only  some  10  to  20  mm.  lower,  such  cases  are  always 
in  shock  and  blood  pressure  is  low.  These  cases  frequently  die.  A 
man  with  the  ordinary  symptoms  of  shock,  whose  systolic  is  65  or 
below,  rarely  recovers.  One  whose  blood  pressure  is  low  from 
hemorrhage  alone,  will  frequently  recover  with  salt  infusions.  Or- 
dinary hemorrhage  unaccompanied  by  fatigue  or  cold,  does  not 
reduce  the  blood  pressure  materially. 

The  author  discusses  briefly  the  origin  of  shock  in  the  light  of 
clinical  observations  and  recent  physiological  work.  By  exclusion 
it  would  appear  that  the  trouble  begins,  in  the  vast  capillary  sys- 
tem, and  is  characterized  chiefly  by  a  loss  of  blood-plasma  into  the 
tissues,  and  very  possibly  into  the  tissue  cells,  rather  than  into  the 
lymph-spaces.  This,  however,  is  not  equivalent  to  plain  hemor- 
rhage inasmuch  as  the  process  is  apparently  progressive,  so  that 
transfused  blood  is  soon  lost  out  of  the  blood  vessels  just  as  is 
salt  solution.  Attention  is  called  to  the  recent  English  work  con- 
cerning these  points.  The  ultimate  cause  of  shock  still  remains 
undetermined. 

SURGICAL  SHOCK.— Rev.  of  War  Surg,  and  Med.,  May,  1917,  i, 
No.  3. 

More  than  three  decades  ago  the  elder  Gross  defined  shock  as  "  a 
rude  unhinging  of  the  machinery  of  life. ' '  Notwithstanding  all  the 
painstaking  investigations  of  latter-day  surgery,  no  equally  satis- 
factory definition  has  been  furnished.  One  after  another,  clinicians 
and  laboratory  men  have  failed  to  link  the  cause  of  shock  with  the 
breakdown  of  any  one  organ  or  set  of  organs.  Up  to  the  outbreak 
of  the  war  no  doctrine  satisfactorily  explained  the  symptom  com- 
plex of  shock. 


354  Abstracts  of  war  surgery 

When  in  August,  1917,  the  Medical  Research  Committee  of  Great 
Britain  appointed  a  special  investigating  committee  to  undertake 
the  correlation  of  laboratory  and  clinical  observations  concerning 
shock,  it  was  natural  to  hope  that  the  tremendous  number  of  unfor- 
tunate war  victims  would  furnish  material  upon  which  to  base  at 
least  a  working  hypothesis.  Unhappily,  this  hope  has  not  been 
realized.  The  report  of  the  special  committee1  develops  much  that 
is  both  interesting  and  valuable,  but  nothing  that  is  fundamen- 
tally creative. 

Frazer  and  Cowell,  who  devoted  themselves  to  the  clinical  study 
of  blood  pressure  in  wound  conditions,  reported  for  the  committee 
as  follows: 

In  Wounds  of  the  Head. — 1.  Scalp  wounds  show  no  appreciable 
alteration  in  blood  pressure. 

2.  Cases  of  compound  fracture  of  the  skull,  with  dura  intact, 
show  a  relatively  high  blood  pressure,  averaging  above  140  mm. 

3.  Penetrating  wounds  of  the  skull  with  free  drainage  are  gen- 
erally associated  with  a  low  blood  pressure — from    60    to  112  mm. 

4.  In  perforating  wounds  the  blood  pressure  would  appear  to 
vary  according  to  the  anatomic  distribution  of  the  wound.  If  the 
pressure  has  involved  the  ventricles,  the  blood  pressure  is  high, 
varying  from  130  to  170  mm. ;  if  the  wound  is  more  superficial 
and  has  not  involved  the  ventricles,  the  blood  pressure  is  low. 

5.  The  blood  pressure  subsequent  to  wounds  of  the  head  is  apt  to 
be  unstable.  If  operation  is  performed  under  general  anesthesia, 
before  the  blood  pressure  has  become  stable,  disaster  is  liable  to 
ensue.  The  possibilities  of  such  an  ill  result  can  be  diminished 
by  delaying  operation  until  the  blood  pressure  can  be  diminished 
or  by  performing  the  operation  under  local  anesthesia. 

In  Abdominal  Wounds. — 1.  In  patients  seen  on  arrival  at  a 
casualty  clearing  station  within  six  hours  of  being  wounded,  if 
there  is  an  intraperitoneal  injury  of  a  hollow  viscus,  the  blood 
pressure  is  low. 

2.  When  a  period  of  from  6  to  10  hours  has  elapsed  the  pressure 
will  probably  have  risen,  for  the  primary  wound  shock  is  now  be- 
ginning to  pass  off — the  rest  on  the  stretchers,  the  warmth  and 
the  sedative  action  of  morphin  are  beginning  to  have  effect. 

3.  At  a  period  later  than  10  hours  the  pressure  begins  to  fall 


iTkis  report  was  published  in  six  papers  in  the  issues  of  Feb.  23  and  Mar.  2,  1918,  of 
the  Jour,  of  Amer.  Med.  Assn. 


ABSTRACTS  OF  WAR  SURGERY  355 

and  a  shockless  condition  becomes  evidenced;  the  change  is  due  to 
sepsis  and  to  loss  of  blood  (secondary  wound  shock). 

4.  Perforating  wounds  of  solid  viscera  of  moderate  severity 
appear  to  be  associated  with  a  relatively  high  blood  pressure ; 
wounds  of  the  liver  and  kidney  often  exhibit  a  systolic  reading  of 
from  130  to  140  mm.,  and  this  even  in  cases  in  which  the  hemor- 
rhage is  considerable. 

5.  Perforating  wounds  of  the  viscera  which  do  not  open  into 
the  peritoneal  cavity  are  associated  with  a  practically  normal  blood 
pressure. 

6.  Large  wounds  of  the  parietes  are  generally  associated  with  a 
lower  blood  pressure  than  small  wounds,  even  though  the  former 
may  have  produced  much  less  visceral  destruction  than  the  latter. 
This  is  probably  explained  by  the  fact  that  in  the  former  instance 
peritoneal  blood  readily  escapes,  while  in  the  latter  the  hemorrhage 
continues  to  be  retained. 

Observations  regarding  the  effect  on  the  blood  pressure  of  open- 
ing the  peritoneal  cavity  showed  that  if  the  abdominal  cavity  con- 
tained a  large  amount  of  blood  there  was  a  very  rapid  fall  of 
pressure  as  soon  as  the  peritoneal  cavity  was  opened  and  the  blood 
allowed  to  escape.  If,  on  the  other  hand,  the  abdominal  cavity  did 
not  contain  much  blood,  the  opening  of  the  abdomen  was  followed 
by  a  temporary  rise  in  blood  pressure  by  as  much  as  20  mm. 
After  10  minutes  the  blood  pressure  fell  to  slightly  below  the 
figure  that  it  registered  before  operation. 

In  Wounds  of  the  Chest. — 1.  Large  open  wounds  of  the  chest 
with  free  entrance  and  exit  of  air  are  accompanied  by  a  profound 
fall  of  blood  pressure. 

2.  Patients  with  uncomplicated  closed  wounds  of  the  chest  who 
arrive  at  the  casualty  clearing  station  well  cared  for  show  normal 
pressure. 

3.  When  severe  internal  hemorrhage  has  occurred  and  the  patient 
has  been  exposed  to  the  cold  for  some  hours,  or  when  infection  has 
become  established,  hypotension  is  present  and  progressive. 

4.  Patients  whose  chest  wounds  are  complicated  by  perforation 
or  laceration  of  the  diaphragm  behave  in  the  same  way  as  class 
2  or  3. 

In  Multiple  Wounds  and  Wounds  of  the  Extremities. — 1.  Com- 
pound fracture  of  the  lower  extremity,  seen  in  the  casualty  clearing 
station,  was  generally  associated  with  a  considerable  fall  in  blood 


356  ABSTRACTS  OF  WAR  SURGERY 

pressure,  more  marked  when  the  fracture  affected  the  region  of 
the  knee-joint. 

2.  Compound  arm  fractures  generally  registered  comparatively 
low  pressure.  The  remarks  that  are  made  as  regards  hemorrhage 
in  wounds  of  the  lower  extremity  equally  apply  in  this  connection. 

3.  In  face  wounds  there  is  not  much  alteration  of  the  blood  pres- 
sure, unless  there  is  an  associated  compound  fracture  of  the  face 
bones,  when  the  pressure  is  generally  lowered. 

4.  Multiple  wounds  of  the  body  and  extremities  were  accom- 
panied by  a  considerable  fall  in  blood  pressure. 

As  Regards  Treatment. — 1.  In  cases  of  profound  shock  accom- 
panied by  loss  of  blood,  excellent  results  are  obtained  from  direct 
blood  transfusion. 

2.  Injection  of  the  calcium  hypertonic  gum  acacia  solution  will 
produce  an  immediate  rise  of  pressure  in  hemorrhage  cases  or  cases 
of  hypotension,  complicated  by  toxemia. 

This  rise  may  tide  the  patient  through  an  operation.  If  the 
source  of  the  infection  is  removed,  the  tension  will  remain  sup- 
ported. 

3.  In  milder  cases  of  shock  and  hemorrhage,  infusion  with  hyper- 
tonic saline  is  useful. 

4.  Results  obtained  after  infusion  with  physiologic  sodium 
chlorid  solution  have  been  unsatisfactory. 

Probably  the  most  baffling  phenomenon  of  shock  is  the  altered 
blood  distribution  leading,  according  to  the  belief  of  many,  to  en- 
gorgement of  the  splanchnic  area.  When  the  cause  of  this  maldis- 
tribution of  blood  is  thoroughly  understood,  we  shall  be  on  the 
road  to  understand  shock.  It  is  interesting  to  note,  in  the  report 
to  the  committee,  made  by  Cannon,  Frazer  and  Hooper,  that  in 
their  investigation  of  the  problem  of  "Alterations  in  Distribution 
and  Character  of  Blood  in  Shock, ' '  they  point  out  that :  In  cases 
of  shock  as  seen  at  a  casualty  clearing  station  in  conditions  of  war- 
fare, the  red  count  of  blood,  taken  from  various  capillaries,  is 
higher  than  that  of  blood  taken  from  a  vein.  The  discrepancy  is 
greater  the  more  profound  the  shock,  and  not  infrequently  is  as 
much  as  2,000,000  corpuscles  per  cubic  millimeter.  Since  the  venous 
count  is  approximately  normal,  the  condition  is  due  to  a  stagnation 
of  corpuscles  in  the  capillaries. 

Cannon,  working  alone,  showed  that  patients  in  shock  were 
also  in  a  condition  of  acidosis,  his  studies  leading  him  to  conclude 
that  cases  of  low  blood  pressure  due  to  shock,  hemorrhage  or  in- 


ABSTRACTS  OF  WAR  SURGERY  357 

fection  with  the  gas  bacillus  have  a  diminished  supply  of  available 
alkali  in  the  blood,  that  is,  an  acidosis.  As  a  general  rule,  the  lower 
the  pressure  the  more  marked  the  acidosis.  The  pulse  is  rapid  in 
these  cases,  but  does  not  vary  with  the  degree  of  acidosis.  The  res- 
piratory rate  becomes  more  rapid  as  the  acidosis  increases  until, 
shortly  before  death,  a  true  ' '  air  hunger ' '  may  prevail. 

Blood  sugar  is  usually  somewhat  increased  above  the  normal  in 
cases  of  shock  and  hemorrhage.  The  acidosis  in  these  cases,  there- 
fore, is  not  due  to  lack  of  circulating  carbohydrate. 

Operation  on  men  suffering  from  shock  and  acidosis  results  in 
serious  and  rapid  sinking  of  arterial  pressure  when  it  is  already 
low,  and  in  marked  and  sudden  decrease  of  the  alkali  reserve  in  the 
blood  when  that  reserve  likewise  is  already  low.  This  change  may 
not  occur  if  nitrous  oxid-oxygen  anesthesia,  instead  of  ether,  is 
employed,  but  that  anesthetic  affords  no  guarantee  against  the 
ominous  decline. 

Shocked  men  suffering  after  operation  from  extreme  acidosis 
with  "air  hunger"  can  be  quickly  relieved  of  their  distress  by  in- 
travenous injection  of  a  solution  of  sodium  bicarbonate,  and  their 
blood  pressure  restored  to  normal. 

Cannon  further  amplifies  his  argument  in  favor  of  acidosis  as 
the  prominent  factor  in  shock  in  his  report  on  "The  Nature  of 
Wound  Shock. ' '  In  this  report  he  analyzes  some  of  the  more  im- 
portant theories  of  shock,  showing  them  all  to  be  inadequate.  After 
this  he  attempts  to  show  that  the  blood  in  shock  is,  as  it  were,  redis- 
tributed, with  stagnation  in  the  capillaries.  The  facts  derived 
from  various  studies,  in  Cannon's  opinion,  warrant  the  conclusion 
that  the  capillary  capacity  is  sufficient  to  contain  the  lost  blood  in 
shock,  and  that  the  chances  of  its  doing  so  are  greater  the  more 
concentrated  the  lost  blood.  Alterations  in  the  viscosity  of  the 
blood  are  thought  to  be  favorable  to  capillary  stagnation  of  the  cor- 
puscles. Concentration  of  corpuscles,  lowered  temperature,  and 
increase  of  H-ions  are  conditions  tending  to  increase  the  viscosity 
of  the  blood. 

The  state  of  acidosis  which  Cannon  makes  responsible  for  the 
capillary  congestion,  and  blood  concentration,  has  also  other  im- 
portant effects :  ( 1 )  There  is  evidence  that  acid  or  change  in  the 
blood  in  the  direction  of  acidity  may  have  depressive  effects  on  the 
blood  pressure;  (2)  Increase  of  carbonic  acid  of  the  blood  affects 
cardiac  contraction;  (3)  Increase  of  carbonic  acid  increases  the 
viscosity  of  the  blood;  (4)  The  size  of  corpuscles  is  increased  by 
the  action  of  carbonic  and  other  acids. 


358  ABSTRACTS  OF  WAR  SURGERY 

Cannon  presents  the  following  concept  of  the  development  of 
shock  or  exemia  ("drained  of  blood")  in  a  correlation  of  the  facts 
developed  in  the  course  of  the  investigations  into  the  nature  and 
treatment  of  wound  shock  and  allied  conditions.  The  facts  are 
listed  as  follows : 

There  are  primary  wound  shock  with  rapid  lowering  of  arterial 
pressure,  and  secondary  wound  shock  with  toxemia  and  hemorrhage, 
and  later  lowering  of  the  pressure.  Sweating  occurs,  leading  to  loss 
of  fluid  and  loss  of  heat  from  the  body.  The  blood  becomes  stag- 
nant and  concentrated  in  the  capillaries,  and  as  the  blood  pressure 
falls  there  is  loss  of  the  alkali  reserve  of  the  blood  (acidosis) 
roughly  corresponding  to  the  drop  in  pressure. 

Primary  wound  shock — dusky  pallor;  rapid,  thready,  low  ten- 
sion pulse,  hypotension;  sweating;  thirst,  and  restlessness — may 
come  on  as  soon  after  the  injury  as  to  be  accounted  for  only  as  the 
result  of  nervous  action.  The  organization  of  the  individual  (for 
example,  a  "high  strung"  temperament),  fear  and  fatigue  probably 
provide  favorable  conditions  for  the  nervous  response.  Cowell's 
observation  of  fainting  after  slight  wounds  may  perhaps  be  re- 
garded as  a  transient  state  which  in  true  shock  is  more  persistent. 
Sweating  and  exposure  lead  to  rapid  loss  of  heat  from  the  body; 
previous  sweating,  wetness  of  the  clothing,  and  low  external  temper- 
ature favor  the  process.  Inactivity  of  the  wounded  man  and  ab- 
sence of  shivering  lessen  heat  protection.  Thus  the  body  becomes 
cold,  especially  the  surface  and  extremities.  In  consequence  of  the 
low  blood  pressure,  aided  by  chilled  tissues,  there  is  a  stagnation  of 
corpuscles  in  the  capillaries.  The  onward  flow  here  checked  under- 
goes concentration,  so  that  the  capillary  red  count  is  high.  Pro- 
longed lack  of  fluid  and  sweating  may  favor  the  stagnation  and 
further  concentration  of  the  blood.  The  low  arterial  pressure  can 
continue  a  flow  through  easy  channels,  but  is  insufficient  to  main- 
tain the  normal  flow  where  resistance  is  high.  Thus  cooled  regions 
receive  less  heat  from  the  interior  of  the  body  and  tend  to  become 
cooler,  and  thus  in  turn  more  blood  accumulates.  By  accumulation 
in  capillaries  the  return  of  blood  to  the  heart  is  lessened  until  a 
persistent  low  blood  pressure  becomes  established.  The  blood  lost 
from  currency  produces  a  state  equivalent  to  hemorrhage.  Any 
true  hemorrhage  therefore  exaggerates  the  existent  shock  (exemia). 

When  a  wound  has  not  caused  a  primary  fall  of  blood  pres- 
sure, but  has  rendered  the  control  of  the  circulation  unstable, 
unfavorable  conditions,  such  as  cold,  hemorrhage,  and  toxemia, 


ABSTRACTS  OF  WAR  SURGERY  359 

will  bring  about  the  same  sequence  of  events  that  is  seen  in  primary 
shock. 

As  the  low  blood  pressure  continues,  the  alkali  reserve  of  the 
blood  is  reduced  (acidosis).  Previous  starvation  and  fatigue 
would  favor  the  development  of  acidosis.  This  state,  by  locally  re- 
laxing vessels  which  are  not  under  nervous  control,  by  weakening 
cardiac  contraction,  and  by  increasing  the  viscosity  of  the  blood, 
tends  to  make  worse  the  dangerous  condition  which  has  been  es- 
tablished. And,  as  pointed  out  in  an  earlier  paper,  the  individual 
with  acidosis  is  sensitized  so  that  operation,  because  still  further 
increasing  the  acidosis  and  still  further  lowering  blood  pressure, 
becomes  hazardous. 

This  conception  of  the  events  that  take  place  in  a  wounded  man 
who  passes  into  shock  gives  a  reasonable  account  of  the  primary 
effect  of  wounds,  the  influence  of  cold  in  continuing  the  low  blood 
pressure  or  inducing  it  when  the  circulatory  apparatus  is  unsta- 
ble, the  influence  of  warmth  in  restoring  him  in  part  to  a  fit  condi- 
tion, and  the  slowness  of  a  full  recovery.  It  leaves  unsettled  the 
occasion  for  the  primary  fall  of  pressure,  though  the  suggestion  is 
offered  that  it  may  be  of  reflex  character,  similar  to  fainting.  The 
conception  offers  a  hopeful  outlook  for  the  care  of  the  shocked  man, 
because  two  of  the  most  potent  factors  making  his  chances  unfav- 
orable— cold  and  acidosis — can  be  controlled. 

In  a  final  paper  the  research  committee  deals  with  the  problem 
of  the  "preventive  treatment  of  wound  shock."  In  this  paper 
nothing  is  added  to  the  comparatively  well-known  principles  of 
civil  surgery — warmth,  quiet,  rest,  and  posture — although  admir- 
able ingenuity  is  displayed  in  adapting  these  principles  to  the  exi- 
gencies of  warfare. 

The  one  new  phase  of  treatment  recommended  by  the  committee 
is  the  injection  of  a  4  per  cent  solution  of  sodium  bicarbonate  or  of 
4  per  cent  bicarbonate  in  6  per  cent  acacia  solution.  They  lay  stress 
on  the  fact  that  the  solution  must  be  sterilized  and  emphasize  that 
sodium  bicarbonate  solution  can  not  be  boiled.  The  salt  itself  must 
be  sterilized,  but  since  the  salt  is  also  broken  up  by  heat  it  is  un- 
fortunate that  the  committee  does  not  state  that  it  can  be  effectively 
autoclaved  in  a  sealed  ampoule  (the  carbon  dioxide  that  is  driven 
off  during  sterilization  is  later  taken  up  by  the  sodium  carbonate, 
converting  it  back  to  bicarbonate). 

It  will  be  noted  that  there  is  nothing  in  these  various  papers  that 
may  be  construed  as  fundamentally  new.    They  do,  in  admirable 


360  ABSTRACTS  OF  WAR  SURGERY 

fashion,  restate  the  shock  problem,  analyze  clinical  phenomena,  and 
emphasize  the  role  of  acidosis  as  causative  factor  and  of  sodium 
bicarbonate  as  a  rational  therapeutic  agent.  Unfortunately,  the 
usual  element  of  lack  of  confirmation  fogs  the  issue,  as  it  always 
has  fogged  the  shock  problem.  As  early  as  1913  Seelig,  Tierney, 
and  Rodenbaugh  (Am.  Jour.  Med.  Sc,  August,  1913,  p.  195) 
studied  Sodium  Bicarbonate  and  Other  Allied  Salts  in  Shock,  reach- 
ing conclusions  somewhat  at  variance  with  the  idea  of  acidosis  as  a 
primary  causative  agency  in  shock.  Very  recently  McElroy  (Jour. 
Am.  Med.  Assn.,  March  23,  1918,  p.  846),  working  on  the  shock 
problem  from  the  experimental  point  of  view,  reached  the  conclu- 
sion that  acidosis  is  not  an  important  primary  causative  factor  in 
shock,  but  was  rather  to  be  construed  as  one  of  the  many  associated 
secondary  changes.  Still  more  recently  one  of  the  American  Medi- 
cal Reserve  Corps  officers  now  serving  with  a  base  hospital  abroad 
expressed  himself  as  follows,  in  a  letter : 

"The  treatment  of  shock  is  about  where  it  always  has  been  with 
the  added  ray  of  hope  that  some  good  men  are  at  work  upon  it. 
It  is  difficult  to  conceive  of  shock  as  due  to  acidosis.  A  little  thought 
tends  to  confuse  one,  because  the  most  severe  acidosis  encountered 
clinically,  namely  in  diabetes,  never  produces  symptoms  of  surgical 
shock.  That  acidosis  is  present  is  almost  to  be  expected,  because  the 
failure  of  the  circulation  results  in  a  failure  on  the  part  of  the  lung 
to  properly  oxygenate  the  blood,  a  necessary  and  natural  increase 
of  the  CO2  content  and,  therefore,  again  naturally  and  logically,  a 
diminution  of  the  alkali  reserve;  and  also  the  sodium  bicarbonate 
infusions  do  no  more  good  in  practice  than  anything  else.  I  should 
say  that,  as  always,  common  sense  and  trust  in  God  still  remain  the 
best  treatment  of  shock. ' ' 

Among  the  men  referred  to  in  the  above  paragraphs  as  being  at 
work  is  Prof.  W.  T.  Porter,  of  the  Harvard  Medical  School.  Prof. 
Porter  has  kindly  summarized  his  later  views  on  the  shock  problem, 
for  presentation  in  this  issue,  as  follows : 

"An  understanding  of  the  critical  level  of  the  blood  pressure  is 
of  the  first  importance  in  the  study  and  treatment  of  shock.  If  the 
blood  pressure  just  touches  the  critical  level,  a  difference  of  10 
millimeters  of  mercury  may  be  the  difference  between  life  and 
death.  A  few  millimeters  above  this  level,  recovery  will  usually 
occur  spontaneously;  a  few  millimeters  below,  death  will  follow 
unless  skilled  aid  be  at  hand.  It  follows  from  this  vital  fact  (1) 
that  procedures  which  at  ordinary  blood  pressures  are  not  harmful. 


ABSTRACTS  OF  WAR  SURGERY  361 

or  are  but  slightly  harmful,  may  kill  the  patient  at  the  critical 
level ;  (2)  remedies  that  raise  the  blood  pressure  but  10  or  15  milli- 
meters will  save  the  patient  when  this  rise  carries  the  blood  pres- 
sure from  just  below  to  just  above  the  critical  level. 

' '  The  critical  level  of  the  diastolic  blood  pressure  in  shock  is  not 
far  from  60  mm. 

' '  The  critical  level  varies  with  the  condition  of  the  nerve  cells  and 
other  tissues.  A  blood  pressure  raised  by  the  surgeon  to  a  point 
above  the  usual  critical  level  may  shortly  sink  again.  Hence  the 
importance  of  frequent  readings  of  the  blood  pressure  until  shock 
patients  are  clearly  out  of  all  danger.  Treatment  not  based  on 
repeated  readings  of  the  blood  pressure  is  not  intelligent  and  may 
be  harmful. 

"The  diastolic  blood  pressure  should  be  employed  in  shock.  In 
this  condition,  the  heart  beats  feebly.  The  systolic  pressure  falls 
more  than  the  diastolic  pressure  falls.  Conversely,  when  remedies 
are  used,  they  often  raise  the  systolic  pressure  more  than  they  raise 
the  diastolic  pressure.  Conclusions  drawn  from  the  systolic  pres- 
sure may  easily  err  15  mm.  or  more.  But  in  shock  the  blood  pres- 
sure is  at  a  critical  level ;  a  change  of  even  15  mm.  may  be  a  matter 
of  life  or  death.  The  error  in  using  the  systolic  instead  of  the 
diastolic  pressure  may  therefore  do  much  harm. 

"In  the  summer  of  1916,  during  my  service  in  the  fighting  line 
in  France,  I  learned  that  in  this  war  shock  occurs  chiefly  after 
shell  fractures  of  the  femur  and  after  multiple  wounds  through 
the  subcutaneous  fat.  In  1,000  casualties,  observed  by  me  at  the 
Massif  de  Moronvillers,  these  were  the  only  injuries  producing 
shock,  except  certain  abdominal  wounds  in  which  the  shell  frag- 
ments undoubtedly  disturbed  the  vasomotor  apparatus  of  the  larg- 
est vascular  area  in  the  body.  It  has  long  been  known  that  fat  em- 
bolism takes  place  after  fractures  of  the  thigh  and  after  multiple 
wounds  through  the  subcutaneous  fat. 

"In  February,  1917,  I  proved  that  the  injection  of  a  small  quan- 
tity of  neutral  olive  oil  in  the  jugular  vein  was  followed  by  a  falling 
blood  pressure  and  other  symptoms  of  traumatic  shock.  The  re- 
sulting publication  was  the  first  clear  statement  that  shock  as 
seen  on  the  battlefield  is  frequently,  perhaps  usually,  caused  by  fat 
embolism. 

"Shortly  thereafter  I  developed  a  remedy  for  the  treatment  of 
shock.  It  has  long  been  known  that  the  pumping  action  of  the 
diaphragm  is  an  important  aid  in  the  movement  of  blood  from 
the  abdomen  into  the  chest.    At  the  height  of  a  strong  inspiration 


362  ABSTRACTS  OF  WAR  SURGERY 

the  venous  pressure  in  the  chest  may  be  40  mm.  lower  than  the 
venous  pressure  in  the  abdomen.  I  produced  strong  respiratory- 
movements  of  the  diaphragm  by  allowing  the  animal  to  breathe 
an  atmosphere  rich  in  carbon  dioxide.  The  diastolic  arterial  pres- 
sure was  thereby  increased  15  and  even  30  mm. 

"In  June,  1917,  at  the  Chemin  des  Dames,  I  successfully  applied 
this  method  to  the  treatment  of  wounded  soldiers.  In  cases  almost 
pulseless,  cases  in  which  all  other  means  of  raising  the  blood  pres- 
sure had  failed,  the  carbon  dioxide  respiration  strengthened  the 
pulse  and  raised  the  diastolic  blood  pressure  10  mm.  This  rise  is  of 
great  value  when  the  pressure  is  at  the  critical  level. 

' '  The  general  treatment  employed  by  me  at  the  Chemin  des  Dames 
was  as  follows:  A  shock  room  was  made  next  the  operating  room. 
The  patient  was  carried  to  the  shock  room  directly  from  the  am- 
bulance. He  was  not  washed.  He  was  at  once  placed  on  an 
operating  table,  inclined  so  that  the  feet  were  30  cm.  higher  than 
the  head.  An  electric  heater  was  put  between  the  blankets  and 
the  body.  The  diastolic  pressure  was  taken  every  15  minutes. 
Where  indicated,  injections  of  warm  normal  saline  solution  were 
made  into  a  vein.  If  his  state  was  grave,  adrenalin  was  added 
to  the  saline  solution.  When  his  condition  justified  operation, 
the  clothing  was  cut  away  about  the  wound  and  the  area  disin- 
fected. Neighboring  regions  were  covered  with  sterile  cloths. 
He  was  then  moved,  still  in  the  inclined  positon  and  still  on  his 
hot  table,  to  the  operating  room.  The  operation  was  done  under 
local  anesthesia  whenever  possible.  At  its  close  the  patient  was 
wheeled  back  to  the  shock  room,  still  on  the  same  inclined  hot 
table.  I  did  not  leave  him  until  he  was  out  of  danger  or  dead. 
Repeated  readings  of  the  pressure  were  taken.  The  remedies 
were  directed  to  raising  the  diastolic  pressure  to  a  point  about 
15  mm.  above  the  critical  level — more  is  not  necessary.  Carbon 
dioxide  respiration  was  frequently  employed  with  benefit.  One 
case  was  operated  on  during  the  carbon  dioxide  breathing,  with 
apparent  advantage. 

"Under  these  methods  four-fifths  of  the  patients  recovered. 

"A  word  as  to  details  may  be  of  interest. 

"Normal  saline  solution  should  be  injected  at  39°  C,  measured 
by  a  thermometer  in  the  vertical  limb  of  a  T  tube  placed  next 
the  cannula.  If  the  pressure  has  not  remained  too  long  below 
the  critical  level,  it  will  be  raised  by  the  normal  saline;  other- 
wise not,  because  the  permeability  of  the  vessel  walls  is  increased 
by  prolonged  low  pressures.    Prof.  Bayliss  states  that  the  addi- 


ABSTRACTS  OF   WAR  SURGERY  363 

tion  of  5  per  cent  of  gum  arabic  to  the  saline  solution  will  pre- 
vent leakage  and  thus  raise  the  pressure  under  all  circumstances. 
This  suggestion  was  made  after  my  leaving  France  and  I  have 
had  no  personal  experience  of  its  value. 

"Adrenalin  is  of  temporary  advantage,  but  even  this  fleeting 
rise  of  blood  pressure  may  save  life.  In  the  laboratory,  the  blood 
pressure  of  animals  may  be  raised  for  considerable  periods  by 
allowing  the  well  diluted  adrenalin  to  flow  into  the  vein  drop  by 
drop  from  a  burette.    I  have  not  tried  this  on  men. 

"Dr.  Meltzer  very  recently  stated  that  the  pressor  action  of 
epinephrin  is  much  prolonged  when  the  drug  is  injected  into  the 
vertebral  canal. 

"The  carbon  dioxide  respiration  should  not  be  stopped  too 
abruptly. ' ' 

FLUID  SUBSTITUTES  FOR  TRANSFUSION  IN  SHOCK  AND 
HEMORRHAGE.— Rev.  of  War  Surg,  and  Med.,  May,  1918, 
i,  No.  3. 

Closely  allied  with  shock  is  the  problem  of  blood  substitutes. 
In  both  hemorrhage  and  shock,  intravenous  therapy  has  always 
occupied  a  prominent  place.  The  object  in  one  instance  is  to 
supply  bulk  (hemorrhage),  and  in  the  other,  to  overcome  the  dis- 
turbance in  blood  distribution  (shock). 

Eous  and  Wilson  (Jour.  Am.  Med.  Assn.,  Jan.  26,  1918,  p.  219), 
discussing  the  question  of  fluid  substitutes  to  combat  hemorrhage, 
say  that  since  severe  acute  hemorrhage,  even  to  apparent  ex- 
sanguination,  does  not  entail  permanent  damage  to  the  organ- 
ism, as  is  shown  by  the  rapid  and  complete  recovery  that  usually 
follows  transfusion,  the  question  arises  whether  such  recovery 
may  be  expected  to  follow  when  another  fluid  than  blood  is  used, 
or  whether  this  is  essentially  dependent  on  the  new  supply  of 
corpuscles  and  plasma. 

The  important  role  of  the  plasma  in  the  rapid  and  complete 
recovery  that  usually  follows  transfusion  has  been  investigated 
by  Abel,  Rowntree,  and  Turner  (Jour.  Pharmac.  and  Exper. 
Therap.,  1914,  v.,  p.  625),  who  demonstrated  that  the  healthy  body 
will  withstand  and  quickly  repair  great  losses  of  the  fluid.  The 
first  point  taken  up  by  Rous  and  Wilson  had  reference  to  the 
ability  of  the  healthy  body  to  withstand  similar  losses  of  red 
cells  only,  or,  more  properly  speaking,  of  functioning  hemoglobin 
— a  point  not  previously  investigated. 

From  their  experiments  with  rabbits,  in  which  they  were  able 


364  ABSTRACTS  OF  WAR  SURGERY 

to  make  a  reduction  of  from  17  to  18  per  cent,  they  consider  the 
view  justifiable  that,  however  desirable  it  may  be,  it  is  not  es- 
sential to  supply  blood  corpuscles  in  ordinary  cases  of  acute 
hemorrhage.  Even  in  the  worst  examples,  the  body  retains  at 
least  twice  the  minimum  functioning  hemoglobin,  which,  if  other 
factors  are  favorable,  will  support  life. 

The  limits  of  substitution  for  plasma  are  directly  dependent 
on  the  time  taken  for  the  plasma's  removal  and  that  allowed  for 
recovery.  When  both  are  generous,  the  possibilities  as  regards 
plasma  withdrawal  and  substitution  are  practically  unlimited. 
Unfortunately,  in  cases  of  hemorrhage  the  depletion  is  extremely 
rapid  and  involves  both  cells  and  plasma.  New  fluid  is  required, 
not  merely  to  replace  the  plasma,  but  also  to  make  up  the  total 
blood  bulk. 

The  ability  of  plasma  to  replace  whole  blood  was  studied. 
When  more  than  half  the  total  calculated  blood  volume  had  been 
taken,  and  the  carotid  pressure  had  fallen  to  a  physiologic  zero 
(from  10  to  20  mm.  of  mercury),  it  was  instantly  and  permanently 
restored  to  the  normal  by  the  injection  of  an  equivalent  quantity  of 
plasma.  This  was  the  case,  too,  when  horse  serum  was  used. 
A  saline  solution  (Ringer's  fluid),  on  the  other  hand,  brought 
about  only  a  slight  transient  recovery  of  the  pressure.  Some- 
times, nevertheless,  the  animal  survived  for  the  half  hour  or  more 
necessary  for  the  successful  utilization  of  its  own  fluid  resources. 

In  studying  the  relative  merits  of  blood  substitutes  Rous  and 
Wilson  tested  several  fluids  made  with  gelatins  which  answered  to 
Hogan's  (Jour.  Am.  Med.  Assn.,  Feb.  17,  1915,  p.  721)  require- 
ments for  purity  and  ability  to  "gel."  While  these  solutions  un- 
doubtedly restored  blood  pressure  better  than  did  salt  solution, 
their  effect  was  soon  lost. 

Hogan  used  2.5  per  cent  gelatin;  Bayliss  6  per  cent,  Rous  and 
Wilson  found  that  larger  concentrations  of  gelatin  up  to  6  per 
cent  act  proportionately  better  than  Hogan's  solution.  In  their  ex- 
perience, in  some  instances,  4  per  cent  gelatin  restores  blood  pres- 
sure permanently,  but  in  others  it  does  not,  whereas  6  per  cent 
gelatin  was  always  effective.  Eight  per  cent  dextrin  in  salt  solu- 
tion, and  5.4  per  cent  glucose  in  Ringer's  solution— a  fluid  with 
twice  the  tonicity  of  blood — were  found  to  exert  only  a  slight  tran- 
sient effect  to  raise  the  blood  pressure  in  bled  rabbits. 

Bayliss  has  recently  (Arch.  Med.  beige,  1917,  lxx,  p.  793)  ad- 
vocated 7  per  cent  gum  acacia  as  a  blood  substitute.  It  can  be 
sterilized  by  boiling,  whereas  the  autoclaving  of  gelatin  is  neces- 


ABSTRACTS  OF  WAB  SUBGERY  365 

sary  in  order  to  kill  tetanus  spores.  It.  is  more  uniform,  in  con- 
stitution than  commercial  gelatin,  and,  being  protein  free,  it 
does  not  induce  anaphylaxis  or  severe  reactions  that  often  fol- 
low the  latter.  Rous  and  Wilson  were  able  to  confirm  the  state- 
ment of  Bayliss  that  7  per  cent  gum  acacia  will  permanently 
restore  blood  pressure  to  normal. 

Bayliss  studied  ox  serum,  2  per  cent  wheat  starch,  1.7  per 
cent  amylopectin,  7  per  cent  acacia  with  calcium  and  also  with 
sodium,  and  6  per  cent  gelatin.  He  reached  the  following  con- 
clusions : 

When  the  arterial  pressure  is  low  from  the  loss  of  blood, 
it  can  not  be  brought  back,  except  to  a  certain  degree,  by  the 
injection  of  saline  solution  in  volume  equal  to  that  of  the  blood 
lost.  But  if  the  viscosity  of  such  solutions  is  raised  to  that  of 
the  blood,  a  return  to  normal  height  is  possible. 

The  effect,  of  saline  injections  is  also  much  less  lasting  than 
that  of  solutions  containing  gum  or  gelatin.  The  difference  in 
this  case  is  due  to  the  osmotic  pressure  of  the  colloids,  by  which 
loss  of  water  by  the  kidneys  and  to  the  tissues  is  prevented. 
Solutions  containing  gum  do  not  produce  edema  in  artificial 
perfusion  of  organs. 

When  the  fall  of  blood  pressure  is  due  to  peripheral  vasodila- 
tation, gum  or  gelatin  solutions,  although  more  effective  than 
pure  saline,  produce  a  much  less  permanent  rise  than  in  cases 
of  loss  of  blood.  No  signs  of  heart  failure  could  be  detected 
and  the  cause  of  the  fall  of  the  raised  pressure  to  its  original 
height  is  still  obscure. 

At  the  British  front,  according  to  Rous  and  Wilson,  where 
acacia  solutions  are  now  used,  the  higher  percentages  have 
been  abandoned  in  favor  of  a  2  per  cent  fluid;  the  results  have 
been  encouraging  but  not  convincing.  A  2  per  cent  acacia  solu- 
tion at  first  raises  the  pressure  to  normal,  but  it  drops  off  with- 
in a  few  minutes  to  the  danger  point.  Four  per  cent  is  more 
satisfactory,  as  the  secondary  drop  in  pressure,  being  slow,  is 
better  compensated.  But  neither  the  4  per  cent  nor  the  5  per 
cent  solution  recommended  by  Hurwitz  {Jour.  Am.  Med.  Assn., 
Mar.  3,  1917,  p.  699)  is  effective  in  all  cases.  Six  or  seven  per 
cent  is  required  if  one  is  to  bring  back  the  normal  pressure  in 
an  organism  depleted  of  its  fluid  reserves. 

The  indications  are  that  horse  serum  would  be  an  effective 
blood  substitute,  except  for  the  risk  of  inducing  sensitization 
or  causing  anaphylactic  shock. 


366  ABSTRACTS  OF  WAR  SURGERY 

Their  investigations  and  conclusions  are  summarized  by  Rous 
and  Wilson  as  follows : 

"The  animal  organism  will  withstand  an  abrupt  reduction  in 
hemoglobin  to  almost,  if  not  quite,  the  low  percentage  that  is 
tolerated  in  chronic  anemia.  Roughly  speaking,  three-quar- 
ters of  the  total  hemoglobin  may  be  safely  removed,  provided 
the  blood  bulk  is  maintained.  If  four-fifths  is  suddenly  with- 
drawn, the  animal  becomes  apathetic,  shows  symptoms  of  air 
hunger,  and  dies  in  a  few  hours.  The  amount  of  hemoglobin 
which  remains  after  fatal  acute  hemorrhage  is  far  above  the 
minimum  requirement  of  the  body.  As  Abel  and  his  coworkers 
have  shown,  great  losses  of  plasma  are  soon  repaired  by  the 
organism,  if  only  the  blood  bulk  is  maintained.  Taking  all 
facts  together,  Rous  and  Wilson  believe  the  conclusion  warrant- 
able that  however  desirable  transfusion  may  be  (especially  to 
furnish  the  elements  needed  in  clotting,  to  lessen  acidosis,  to 
improve  oxygenation,  etc.)  it  is  not  essential  to  recovery  from 
even  the  severest  acute  hemorrhage,  if  only  the  blood  bulk  can  be  re- 
stored in  other  ways. 

"Of  the  several  fluid  substitutes  for  transfusion  which  have 
recently  been  suggested,  all  are  preferable  to  salt  solution. 
Bayliss'  7  per  cent  gum  acacia  solution  is  up  to  the  pres- 
ent time  the  best,  and  its  use  should  save  life  in  many  instances. 
In  less  urgent  cases,  from  2  to  3  per  cent  acacia  solution,  or 
Hogan's  2.5  per  cent  gelatin  solution,  are  to  be  preferred  to 
salt  solution.  But  these  fluids  leave  the  circulation  relatively 
soon,  and  when  the  organism  has  been  drained  of  its  fluid  re- 
sources their  injection  restores  the  blood  pressure  to  the  nor- 
mal level  for  only  a  few  minutes.  Permanent  betterment  can 
not  be  expected  in  cases  of  severe  hemorrhage  with  solutions 
containing  less  than  from  5  to  7  per  cent  gum  acacia.  It  is 
not  essential  that  a  blood  substitute  should  possess  the  viscos- 
ity of  whole  blood." 

As  regards  shock,  in  its  relationship  to  blood  substitutes,  the 
problem  is  somewhat  different  from  that  of  hemorrhage.  The 
general  tendency  is  to  distrust  more  and  more  the  various  salt 
solutions  and  to  pin  more  and  more  faith  to  the  colloidal  solu- 
tions. Of  these,  the  acacia  solution  ranks  in  popularity  next 
to  actual  blood.  The  recent  work  of  Erlanger  and  Woodyat 
{Jour.  Am.  Med.  Assn.,  Oct.  27,  1917,  p.  1410)  lends  a  rational 
hope  for  the  use  of  glucose  solution  in  shock.  These  authors  report 
that: 


ABSTRACTS  OF  WAR  SURGERY  367 

Glucose  injected  intravenously  at  rates  varying  between  0.57 
and  4  gm.  per  kilogram  per  hour  for  from  20  to  60  minutes 
into  anesthetized  dogs  reduced  to  a  state  of  "shock"  (by  partial 
temporary  occlusions  of  the  inferior  cava  or  aorta)  has  been 
observed  uniformly  to  increase  the  mean  arterial  pressure. 

The  injections  have  uniformly  produced  a  marked  increase 
in  the  pulse  amplitude,  indicating  a  condition  of  plethora. 

The  increase  in  pulse  amplitude  has  usually  been  more  strik- 
ing than  the  increase  in  arterial  pressure. 

In  one  case  the  increase  in  pressure  determined  by  the  infec- 
tion of  glucose  continued  after  the  cessation  of  the  injection 
until  the  pressure  was  approximating  the  normal. 

A  subtolerant  dose  has  raised  the  arterial  pressure  and  in- 
creased the  pulse  amplitude  as  effectively  as  many  of  the  injec- 
tions made  at  more  rapid  rates. 

With  the  more  rapid  injections,  a  marked  hemorrhagic  tend- 
ency may  develop  in  animals  in  this  condition. 

No  other  palpable  deleterious  effects  were  observed. 

The  conclusion  is  drawn  that,  on  theoretical  and  experimental 
grounds,  supported  by  some  clinical  evidence,  it  would  appear 
that  intravenous  injections  of  glucose  at  appropriate  rates  are 
of  distinct  benefit  in  certain  phases  of  shock. 

No  discussion  of  transfusion  (whether  blood  or  blood  substi- 
tutes be  used)  is  complete  without  a  word  of  caution  regarding 
the  potential  harm  that  is  essentially  resident  in  this  procedure. 
Well  intentioned  therapy  may,  by  actual  disturbance  of  blood 
chemistry,  by  anaphylactic  reaction,  or  by  embarrassment  of 
an  enfeebled  right  heart,  result  in  the  sacrifice  of  a  patient 
who  might  have  been  saved  by  the  conservation  of  his  own 
forces,  through  the  judicious  use  of  warmth,  posture,  rest,  and 
morphine. 


FOREIGN  BODIES 

SIMPLE  METHOD  OF  LOCALIZATION  OF  FOREIGN 
BODIES. — J.  S.  Young.  Arch.  Radiol,  and  Electrotherap., 
1917,  xxii,  p.  40. 

The  method  employed  by  the  author,  as  described  by  him- 
self, consists  simply  in  the  use  of  a  small  apparatus,  with  an 
aluminum  base,  which  rests  underneath  the  part  which  con- 
tains the  foreign  body,  and  an  upright  standard  which  rests 
upon  the  broad  end  of  the  aluminum  base.  This  standard  has 
two  adjustable  cuffs,  an  upper  and  a  lower,  through  each  of 
which  a  rod  passes.  The  upper  rod  has  a  loop  on  its  end,  while 
the  lower  has  a  small  metallic  ball.  These  rods  are  both  ad- 
justable in  two  directions,  and  are  secured  by  two  set-screws. 

The  patient  is  placed  upon  the  aluminum  base  (tube  of  course 
underneath  table),  the  foreign  body  is  located  by  the  central 
rays,  and  the  loop  is  pressed  directly  over  the  same.  After  hav- 
ing pressed  the  loop  on  the  upper  rod  close  to  the  skin  so  that 
there  will  be  no  motion,  the  diaphragm  is  then  opened  and  the 
tube  moved  up  and  down  and  the  ball  then  adjusted  so  that 
it  moves  in  the  same  plane  with  the  foreign  body.  The  foreign 
body  is  thus  located  in  two  directions,  the  ball  locating  it  at 
the  base  line,  and  the  loop  locating  it  in  the  perpendicular  plane. 

The  method  is  perfectly  simple  and  is  absolutely  correct,  if 
the  operator  is  careful  first  in  posing  his  patient,  and  second 
in  observing  that  the  foreign  body  and  ball  move  in  the  same 
plane.  Otherwise  he  will  find  there  is  a  variation  of  from  half 
an  inch  to  two  inches  in  the  lower  plane  of  his  localization. 

THE  LOCALIZATION  OF  FOREIGN  BODIES.— W.  A.  Wil- 
kins.    Am.  Jour.  Roent.,  1917,  iv,  p.  343. 

The  author  dismisses  the  two-plane  and  stereoscopic  methods 
of  localization  by  brief  mention  as  having  only  a  small  field  of 
usefulness.  The  method  of  choice  which  he  has  found  entirely 
efficient  under  conditions  of  active  service  is  a  modification  of 
a  method  described  by  Hampson  some  years  ago  depending 
upon  a  triangulation  calculation.  Two  exposures  are  made 
upon  the  same  plate  with  the  foreign  body  as  nearly  as  possible 

368 


ABSTRACTS  OF  WAR  SURGERY  369 

perpendicularly  above  the  center  of  the  plate.  During  the  first 
exposure  the  center  of  the  target  is  a  known  distance  vertically 
above  the  center  of  the  plate.  This  center  is  indicated  by  cross- 
wires  stretched  on  an  overlying  board  and  these  when  inked 
leave  their  impress  on  the  overlying  skin.  The  second  exposure 
is  made  with  the  tube  shifted  a  known  distance  horizontally  in 
the  direction  of  either  cross-wire.  To  ascertain  the  location  of 
the  foreign  body  in  relation  to  the  center  of  the  cross-wire,  di- 
rect measurement  is  made  after  the  true  position  of  that  body 
has  been  obtained  by  certain  intersecting  lines.  The  depth  of 
the  foreign  body  is  found  by  constructing  right-angled  triangles 
whose  bases  are  represented  respectively  by  the  distances  be- 
tween the  foreign  body  shadow  and  the  shift  of  the  target.  The 
perpendiculars  can  be  ascertained  algebraically  as  the  total  is 
a  known  quantity,  being  the  distance  from  the  target  to  the 
plate.  With  the  ink-marks  of  the  cross-wires  as  guides,  a  final 
mark  is  made  on  the  skin  to  represent  the  spot  beneath  which 
the  foreign  body  lies  at  the  determined  depth. 

A  number  of  cases  to  demonstrate  the  method  are  illustrated 
and  described.  The  author  recommends  it  for  its  simplicity  and 
practicability,  having  tried  it  under  many  and  varied  circum- 
stances to  the  satisfaction  of  all  concerned. 


THE  SUTTON   METHOD    OF    FOREIGN   BODY  LOCALIZA- 
TION.—E.  H.  Skinner.    Amer.  Jour.  Roent.,  1917,  iv,  p.  350. 

The  method  is  best  described  in  the  originator's  own  words 
quoted  from  Binnie's  "Operative   Surgery." 

"Having  located  the  shadow  of  the  foreign  body  by  means 
of  the  axial  ray  upon  a  large  screen,  firmly  supported  about 
six  inches  above  the  surface  of  the  part  examined,  the  surface 
is  painted  with  iodine,  cocainized,  and  a  small  skin  incision  made 
in  the  center  of  the  shadow.  The  special  cannula  bearing  the 
blunt  or  sharp  trocar,  as  circumstances  may  indicate,  and  held 
by  a  strong  clamp  at  right  angles,  is  then  entered  through  the 
skin  incision.  The  room  is  then  darkened  and  under  the  guid- 
ance of  the  x-ray  the  instrument  is  driven  through  the  tissues. 
As  long  as  the  point  is  advancing  straight  toward  the  anode, 
and  hence  toward  the  foreign  body,  the  shadow  of  the  point 
will  be  hidden  by  the  shadow  of  the  upper  portion  of  the  in- 
strument. 

"When  the  trocar  strikes  the  foreign  body,  the  patient  in- 
variably complains  of  a  sharp  pain.     Contact  is  then  verified 


370  ABSTRACTS  OF  WAR  SURGERY 

by  slight  waving  movements  of  the  point  of  the  trocar  which 
can  be  made  to  cause  the  foreign  body  shadow  to  describe  a 
circular  excursion  on  the  screen. 

"The  current  is  now  cut  off,  the  screen  removed,  and  the 
room  lighted  while  the  operator  continues  to  hold  the  trocar 
immovable.  Next  the  trocar  is  withdrawn  from  the  cannula 
and  one  of  the  small  hooked  piano-wire  indicators  inserted  in 
its  place.  Holding  the  hook  of  the  latter  against  the  foreign 
body,  the  cannula  is  withdrawn  and  the  wire  snipped  off  one- 
fourth  inch  above  the  skin.  Over  this  a  fairly  thick  dressing 
is  applied.  If  other  foreign  bodies  are  present,  each  may  be 
localized  in  the  same  way.  On  the  operating  table  each  indi- 
cator may  be  readily  followed  to  the  corresponding  foreign 
body.     The  particular  advantages  of  this  method  are : 

"1.  Operations  may  almost  always  be  done  under  local 
anesthesia. 

"2.  Changes  in  the  position  of  limbs  or  body  do  not  vitiate 
the  result. 

"3.  There  are  no  calculations  to  introduce  a  possible  mathe- 
matical error. 

"4.  The  localization  may  be  carried  out  aseptically  without 
sterilizing  the  hands." 

This  method  has  simplicity,  ease  and  rapidity  of  application, 
and  absolute  accuracy  to  recommend  it  and  practically  none  of 
the  sources  of  error  or  difficulties  of  application  incurred  with 
the  various  triangulation  or  other  methods  in  use. 

OPERATIVE  REMOVAL  OF  BULLETS  AND  FRAGMENTS 
OF  GRENADES,  WITH  SPECIAL  REFERENCE  TO  THE 
USE  OF  THE  ELECTROMAGNET.— von  Hofmeister. 
Beitr.  z.  klin.  Chir.,  1915,  xcvi,  p.  166.  (Abstr.  by  Surg., 
Gynec.  and  Obst.) 

The  opinion  still  prevails  among  the  laity  that  the  most  im- 
portant thing  to  be  done  in  case  of  gunshot  injury  is  to  re- 
move the  bullet.  Von  Hofmeister  points  out  that  a  metallic 
foreign  body,  as  a  rule,  is  perfectly  harmless  and  the  wound 
heals  without  reaction.  The  mere  presence  of  a  bullet  is  not 
an  indication  for  operation,  nor  is  the  desire  of  the  patient.  If 
phlegmons  or  abscesses  arise,  the  projectile  generally  plays  only 
a  secondary  part  in  their  formation.  The  object  of  operation 
in  these  cases  is  not  primarily  to  remove  the  bullet,  but  to  pro- 
cure free  egress  for  the  secretion.     The  projectile  may  be  re- 


ABSTRACTS  OF  WAR  SURGERY  371 

moved  if  it  lies  in  the  abscess,  so  that  its  removal  is  easy,  but 
the  surrounding  tissue  should  not  be  probed  for  it,  as  removal 
of  the  bullet  or  fragment  is  only  indicated  when  it  is  in  a  loca- 
tion where  it  may  do  further  injury,  as  in  the  eye,  the  bladder, 
the  trachea,  etc.,  where  it  exercises  pressure  on  nerves  or  ves- 
sels or  where  it  interferes  with  the  motion  of  joints,  tendons  or 
muscles. 

It  has  been  claimed  that  lead  bullets  may  produce  toxic  ef- 
fects due  to  lead  poisoning,  but,  though  this  may  be  true  to  a 
certain  extent,  von  Hofmeister  believes  that  the  danger  of  lead 
poison  is  less  than  that  of  operative  interference. 

There  are  two  procedures  which  tempt  surgeons  to  remove 
foreign  bodies  unnecessarily:  (1)  roentgen  photography  and 
(2)  the  use  of  the  electromagnet. 

The  roentgen  picture  shows  the  position  of  the  foreign  body 
so  plainly  it  seems  the  simplest  thing  in  the  world  to  remove 
it.  Von  Hofmeister  thinks  that  it  is  not  justifiable  to  extend 
the  use  of  the  electromagnet  from  ophthalmology  to  general 
surgery.  The  magnet  easily  removes  the  body  from  the  fluid 
media,  of  the  eye,  but  not  through  solid  muscle  or  cicatricial 
tissues. 

Surgeons  should  be  impressed  with  the  fact  that  the  indica- 
tions for  the  removal  of  a  foreign  body  should  be  as  definite  as 
for  any  other  surgical  procedure,  and  no  physician  need  be 
ashamed  to  refer  a  patient  to  a  surgeon  for  this  purpose. 


PERIPHERAL  NERVE  INJURIES 

INJURY  TO  PERIPHERAL  NERVES  —Sir  Berkeley  Moynihan. 
Surg.,  Gynec.  and  Ohst.,  Dec,  1917. 

The  lesion  of  nerve  trunks  as  the  result  of  wounds  inflicted 
in  war  may  be  of  diverse  forms. 

1.  In  the  majority  of  cases  the  nerve  trunk  has  not  sustained 
a  primary  injury.  It  may  be  exposed  in  greater  or  less  degree 
in  a  wound  of  the  soft  parts,  with  or  without  fracture.  If  such 
wounds  are  gravely  infected  and  suppuration  occurs  with,  per- 
haps, necrosis  of  one  or  of  many  fragments  of  bone,  the  pro- 
cess of  healing  may  be  long  delayed,  and  the  cicatricial  tissue 
which  results  will  be  of  exceeding  density.  The  nerve  trunk 
is  strangled,  bereft  of  its  due  supply  of  blood,  and  becomes  in 
consequence  functionless.  It  is  impossible  before  operation  to 
decide  in  the  severer  cases  whether  such  a  nerve  has  or  has 
not  been  completely  divided. 

2.  The  nerve  fibers  may  not  have  been  directly,  or  they  ma- 
have  been  only  very  trivially  implicated,  but  the  projectile  may 
have  passed  so  near  the  nerve  trunk  as  to  have  opened  its 
sheath.  The  nerve  then  becomes  adherent  to  the  track  of  the 
missile,  and  a  mass  of  fibrous  tissue  is  found  firmly  welded  on 
to  its  lateral  aspect.  Or,  the  projectile,  in  this  case  a  rifle  or 
machine  gun  bullet,  may,  at  that  period  of  its  flight  when  it 
has  become  steady,  have  cleaved  through  the  trunk  of  a  nerve 
separating  the  fibers  and  severing  few  or  none.  Hemorrhage 
within  the  sheath  occurs,  and  a  fibrous  mass  develops  in  the 
center  of  the  nerve,  causing  it  to  assume  a  fusiform  appearance. 
There  is  then  a  central  neuroma. 

3.  The  nerve  may  have  been  partly  severed,  say  in  half  its 
diameter,  by  a  projectile,  or  a  fragment  of  bone.  The  gap  in 
the  nerve  is  soon  filled  up  by  fibrous  tissue  which  extends 
widely  upward  and  downward  and  away  from  the  side  of  the 
nerve,  so  that  a  hard  fibrous  lateral  neuroma  is  found. 

4.  The  nerve  may  be  completely  severed.  In  such  a  case  a 
gap  of  greater  or  less  length  is  found  between  the  divided  ends. 
Bridging  this  interval  there  may  be  a  connecting  strand  of 
fibrous  tissue,  or  a  blurred  mass  of  scar  material  in  which  both 
cut  ends  are  lost.     In  some  cases  the  nerve  may  appear  hard 

372 


ABSTRACTS  OF  WAR  SURGERY  373 

and  swollen,  and  as  though  its  fibers  were  continuous ;  but 
careful  dissection  Avill  show  that  there  is  complete  division. 

When  the  nerve  has  been  cut  completely  across,  the  upper 
divided  end  is  soon  found  to  present  a  characteristic  bulbous 
appearance.  On.  section  this  is  seen  to  consist  partly  of  fibrous 
tissue  and  partly  of  nerve  tissue.  From  the  upper  end  of  any 
divided  nerve,  the  axis  cylinders  grow  downward  tirelessly, 
each  one  searching  out  diligently  but  blindly  the  lower  end  to 
which  it  seeks  to  unite.  When  the  quest  fails  in  one  direction 
and  an  uncongenial  tissue  is  met,  the  axis  cylinder  turns  in 
another  direction,  searching  there  fruitlessly  again,  and  so 
twists  itself  in  ceaseless  contortion  until  a  tumor,  a  terminal 
neuroma,  is  formed. 

The  relative  frequency  of  affected  nerves  has  in  Moynihan's 
experience  been  as  follows : 

Nerve  Per  Cent 

Musculospiral    25 

Ulnar    24 

Median 14 

Sciatic    12 

External  popliteal  12 

Internal  popliteal   1 

Upper  portion  of  the  brachial  plexus 4 

Lower  portion  of  the  brachial  plexus   (cords) 7 

Anterior  crural   1 

This  corresponds  fairly  accurately  with  the  experience  re- 
corded by  Gosset  and  by  Tinel. 

Diagnosis. — The  following  points  in  the  clinical  histories  are 
investigated:  date  of  injury;  nature  of  projectile;  position  of 
patient  at  moment  of  injury;  immediate  effects;  after  history 
(including  history  of  operations  performed). 

Physical  examination  consists  in — 

A.  Inspection  of  the  limb  to  note  (1)  attitude,  contractures 
(claw  hands,  etc.)  ;    (2)  position  of  wounds  and  scars. 

B.  Testing  of  the  efferent  impulses:  (1)  Motor  weakness  for 
paralysis,  each  muscle  and  each  muscle  group  being  tested 
separately.  (2)  Trophic  and  vasomotor  disturbances.  Non- 
shedding  of  epidermis,  "glossy  skin,"  ulcers,  changes  in  nails, 
etc.  (3)  Changes  in  deep  tissues,  e.  g.,  muscular  atrophy,  fib- 
rillation, bone  decalcification,  etc. 

C.  Testing  of  the  afferent  impulses:  (1)  Pain,  its  character,  dis- 
tribution, relation  to  hot  and  cold  applications  of  weather. 
(2)  Loss     of     cutaneous     sensibility,     tested     by     standardized 


374  ABSTRACTS  OF  WAR  SURGERY 

stimuli  of  special  instruments  so  that  the  results  are  strictly 
comparable.  Light  touch.  Localization  of  spot  touched.  Tac- 
tile discrimination  (pressure,  texture,  etc.).  Stereognostic 
sense  (size  and  shape  of  three  dimensions)  ;  appreciation  of 
compass  points  applied  simultaneously.  Thermal  stimuli  (hot 
and  cold  test  tubes).  Painful  stimuli  (pinprick  controlled  by 
standardized  spring).  Eoughness  (Graham  Brown  esthesiom- 
eter).  (3)  Deep  sensibility — pressure,  pain,  vibration  sense 
in  bones,  joint  and  muscle  sense,  etc. 

D.  In  the  electrodiagnosis,  the  reactions  to  the  interrupted  cur- 
rent are  tested  by  shocks  from  an  induction  coil,  the  electrode 
being  placed  upon  the  "motor  point"  of  each  muscle  in  turn. 
The  current  from  a  secondary  coil  is  always  used. 

A  positive  reaction  to  faradism  is  regarded  as  a  contraindica- 
tion to  operation,  but  failure  to  respond  gives  no  definite  in- 
formation, for  voluntary  movement  may  return,  after  nerve  in- 
jury, before  the  faradic  response. 

The  muscles  are  next  investigated  by  a  constant  current. 
"Polar  changes"  have  been  found  to  be  of  minor  value;  they 
may  vary  with  the  local  circulatory  changes  following  massage, 
etc.  The  character  of  the  contraction  is  of  much  more  im- 
portance. A  brisk  twitch  indicates  the  probable  presence  of 
some  conduction  nerve  fibers  in  the  muscle  tested,  while  a  slow, 
"vermicular"  response  is  usually  associated  with  a  complete 
interruption  of  nerve  fibers. 

The  nerve  muscle  is  next  examined  by  means  of  a  condenser 
discharge.  The  method  depends  upon  the  fact  that  a  condenser 
discharge,  through  a  constant  resistance,  gives  a  current  which 
varies  in  duration  according  to  the  capacity  of  the  condenser 
used. 

The  more  severe  the  damage  to  the  nerve  the  greater  will  be 
the  capacity  of  the  condenser  required  to  excite  it;  or,  in  other 
words,  the  longer  the  duration  of  the  current  the  more  chance 
is  there  of  obtaining  a  response  in  such  a  nerve  muscle. 

The  whole  advantage  of  the  condenser  method  is  that  a 
definite  measurement  of  current,  or  condenser  used,  may  be 
noted  and  future  progress  may  be  accurately  followed. 

The  condenser  method  is  chiefly  used  in  cases  where  opera- 
tion is  deferred  because  some  function  is  found  to  be  present 
in  a  given  injured  nerve.  (The  work  done  recently  by  E.  D. 
Adrain  and  others  shows  that  the  condenser  is  disappointing  in 
practice;  nevertheless,  it  gives  useful  information  in  recording 
progress.) 


ABSTRACTS  OF  WAR  SURGERY  375 

Complete  absence  both  of  faradic  and  galvanic  response  is  an 
indication  for  early  operation.  The  cases  which  require  care- 
ful and  repeated  examinations  are  those  where  there  is  pres- 
sure on  the  nerve  trunk  by  a  contracting  scar.  In  some  nerve 
trunks  there  is  little  damage  to  some  of  the  fibers  with  total 
loss  in  others.  Operation  must  not  be  deferred  too  long  in  these 
cases,  because  the  fibers  with  complete  reaction  of  degenera- 
tion may  never  recover  on  account  of  a  dense  scar-tissue  forma- 
tion at  the  site  of  injury.  In  other  words,  the  presence  of  a 
degree  of  voluntary  power  in  some  individual  muscles  of  a 
group  supplied  by  a  damaged  nerve  is  no  sure  criterion  that 
the  paralyzed  muscles  will  recover  without  operation. 

It  is  most  important  that  nerve  injuries  should  be  reexamined 
at  frequent  intervals  and  carefully  detailed  records  of  motor 
power,  sensory  changes,  and  electrical  reactions  kept.  In  this 
way  treatment  may  be  modified  according  to  progress. 

In  operations  upon  nerves  where  a  diagnosis  of  total  loss  in 
some  fibers  only  has  been  made,  it  is  Moynihan's  practice  to 
test  the  exposed  nerve  both  above  and  below  the  site  of  injury 
at  the  time  of  operation.  For  this  examination  special  steriliz- 
able  electrodes  and  long  connecting  cords  which  can  be  boiled, 
are  used.  The  nerve  is  gently  lifted  upon  two  small  glass  hooks 
and  a  very  weak  faradic  current  employed. 

The  most  accurate  anatomical  arrangement  of  fibers  may  be 
noted  by  this  means  and  the  knowledge  used  to  secure  perfect 
adaptation  in  nerve  suture.  The  diagnosis  is  often  completed 
during  a  period  in  which  massage,  baths,  and  electrical  treat- 
ment are  employed  to  improve  the  local  circulation,  and  splint 
treatment  adopted  to  relax  affected  muscle  groups  and  to  over- 
come contractures.  The  distinction  between  anatomical  and 
physiological  division  is  not  made  before  operation. 

Operation  is  decided  upon  in  the  following  circumstances : 
(1)  in  cases  of  complete  division;  (2)  in  cases  of  incomplete 
division,  where  progress  is  arrested;  (3)  where  there  is  severe 
neuralgic  pain,  "causalgia. " 

Operation  is  deferred  (1)  for  one  month  after  the  closure  of 
the  wound  where  soft  parts  only  are  injured;  (2)  for  two  or 
three  months  after  complete  closure  of  the  wound  where  bone 
has  been  involved;  and  (3)  definitely  so  long  as  progressive 
signs  of  recovery  in  nerve  functions  continue. 

The  suture  of  the  nerve  may  have  to  be  delayed  until  un- 
satisfactory joint  conditions  are  improved.  Contractures  of  the 
knee  for  example,  should  be  corrected  before  the  sciatic  nerve 


376  ABSTRACTS  OF  WAR  SURGERY 

is  sutured,  otherwise  the  nerve  would  be  in  danger  of  rupture 
if  the  deformity  were  subsequently  rectified.  In  other  cases  the 
nerve  may  be  sutured,  and  the  joint  dealt  with  at  the  same 
period,  and  subsequently.  It  is  of  the  first  importance  to  start 
active  measures  to  prevent  or  remove  stiffness  and  deformity  in 
the  parts  supplied  by  a  wounded  nerve.  This  can  often  be  done 
for  many  weeks  before  it  is  possible  to  repair  the  nerve.  It  is 
not  sufficiently  realized  that  a  nerve  to  be  of  use  after  suture 
must  act  upon  live  and  supple  tissues.  Joints  and  muscles  must 
be  kept  ready  for  the  nerve  impulses  which  some  day  will  come 
to  them  again. 

When  the  diagnosis  of  a  nerve  lesion  requiring  operation  has 
been  made,  the  earliest  prudent  occasion  must  be  chosen  for 
operation.  In  both  the  French  and  British  armies  nowadays 
the  suture  of  a  divided  nerve  is  performed  in  those  most  ad- 
vanced operating  centers  where  the  first  deliberate  toilet  of 
the  wound  is  possible. 

In  many  cases  an  injury  to  bone  may  have  been  inflicted  at 
the  same  moment  as  the  division  of  the  nerve ;  this  is,  of  course, 
frequently  the  case  when  the  musculospiral  nerve  is  implicated. 
Many  loose  pieces  of  bone  may  remain  as  sequestra  in  the 
wound  and  may  need  removal  or  may  escape  spontaneously 
from  time  to  time.  In  all  such  cases,  operation  upon  the  nerve 
must  be  deferred  until  the  wound  has  been  soundly  healed  for 
some  weeks;  no  rule  is  more  binding  upon  the  surgeon  than 
that.  During  this  period,  which  may  be  protracted,  the  most 
diligent  attention  must  be  given  to  the  limb,  especially  to  those 
parts,  muscles  and  joints,  distal  to  the  injury. 

Special  and  unremitting  attention  is  given  to  the  joints,  which 
must  always  be  kept  supple.  Every  day,  many  times  a  day,  all 
the  paralyzed  parts  must  be  freely  moved  to  their  full  range, 
and  the  patient  must  be  instructed  to  attend  to  this  matter  un- 
ceasingly. 

When  the  operation  actually  takes  place  it  is  important  to 
observe  certain  essentials  to  success.  There  must  be  the  most 
perfect  and  scrupulous  asepsis  and  the  most  gentle  handling. 
The  finger  should  never  be  placed  in  the  wound.  All  dissection 
should  be  carried  out  deftly  and  neatly;  the  most  diligent  care 
must  be  taken  never  to  bruise  the  nerve  by  seizing  it,  however 
gently,  in  forceps.  The  nerve  must  never  be  twisted,  or  torn 
or  stretched,  or  unduly  separated  from  its  bed.  Other  struc- 
tures must  be  dissected  from  the  nerve;  the  nerve  must  not  be 
dissected  from  them.     The  nerve  must  not  be  stripped  bare  for 


ABSTRACTS  OF  WAR  SURGERY  377 

too  long  a  distance,  otherwise  it  will  be  devascularized,  and 
recuperative  processes  will  be  slow  or  absent.  The  wound  as  a 
whole,  and  the  nerve  in  particular  must  not  be  allowed  to  dry 
or  to  be  chilled.  The  most  dainty  and  precise  movements  are 
necessary  throughout  and  every  bleeding  point  must  be  thor- 
oughly secured.  There  are,  of  course,  the  observances  that  go 
to  make  up  the  ritual  of  every  well-trained  surgeon;  their 
strict  acceptance  is  more  necessary  here  than  in  almost  any 
other  operation,  if  the  most  rapid  and  the  most  flawless  re- 
covery is  to  be  made  certain. 

As  a  rule  a  tourniquet  is  undesirable.  The  incision  is  de- 
signed to  fall  on  the  skin  at  some  distance  from  the  original 
wound  if  possible ;  very  often  a  flap  will  occur  from  the  mak- 
ing of  a  curved  incision.  The  planning  of  the  incision  gives 
scope  for  one's  knowledge  of  anatomy;  it  is  so  arranged  that 
no  small  nerves  are  wounded. 

The  nerve  trunk  is  sought  above  and  below  the  point  of 
severance,  and  is  traced  downward  and  upward  to  the  gap.  It 
is  his  business  to  know  before  he  begins  these  operations  ex- 
actly where  the  nerve  lies,  and  he  should  always  be  able  to 
cut  directly  down  on  it.  When  the  injured  nerve  is  exposed, 
it  is  usual  to  find  a  bridge  of  fibrous  tissue  between  the  ends; 
the  proximal  end  being  very  often  turgid  and  bulbous.  If  the 
gap  between  the  refreshed  ends  of  the  nerve  is  likely  to  be  wide, 
now  is  the  time  for  stretching  the  nerve,  so  as  to  lessen  the 
interval  as  much  as  possible.  This  is  done  with  infinite  gentle- 
ness and  care  by  seizing  the  fibrous  band  between  the  ends,  and 
drawing  steadily  upward  and  downward,  always  remembering 
to  make  the  pull  in  the  line  of  the  nerve  trunk  and  to  avoid 
twisting.  The  fibrous  band  is  now  split  longitudinally,  and 
then  its  ends  are  divided,  above  in  one  direction,  below  in  the 
other,  so  that  to  each  cut  end  of  nerve  a  fibrous  tag  is  attached 
by  means  of  which  the  nerve  ends  can  be  drawn  together.  Prog- 
ressive transverse  cuts  are  now  made  into  the  nerve  ends  until 
on  the  cross-section  nothing  but  nerve  fibers  are  seen.  Every 
tiniest  particle  of  fibrous  tissue  must  be  removed  or  the  opera- 
tion will  fail.  The  axis  cylinders  coming  from  above  must  have 
free  entry  into  the  nerve  below;  otherwise  in  their  downward 
development  they  will  lose  their  way,  and  restoration  of  the 
nerve  function  will  not  take  place.  When  the  nerve  ends  are 
duly  prepared  they  are  brought  into  apposition  with  the 
greatest  care.  A  series  of  very  fine  catgut  sutures  holding  only 
the  nerve    sheath  are    inserted  at    intervals  round    the  circum- 


378  ABSTRACTS  OF  WAR  SURGERY 

ference  of  the  nerve.  A  suture  is  never  passed  through  the 
substance  of  the  nerve  itself.  In  uniting  the  nerve  ends,  it  is 
of  the  first  importance  to  avoid  axial  rotation.  We  know  now 
that  there  is  a  differentiation  of  function  within  each  nerve  and 
it  is,  therefore  strictly  necessary  to  unite  corresponding  bundles 
of  fibers.  A  nerve  does  not  act  as  a  whole,  but  consists  of  a 
multitude  of  strands  each  with  its  proper  and  restricted  func- 
tion. Unless  nerve  bundles  which  were  originally  continuous 
are  brought  accurately  together  by  suture,  the  nerve  is  com- 
pelled to  rearrange  the  functions  of  its  several  parts.  This  it 
can,  and  no  doubt  frequently  has  to,  do.  An  examination  of 
many  cases  shows,  however,  that  a  perfect  and  flawless  recovery 
after  a  nerve  suture  is  unusual,  and  it  is  at  least  a  tenable  be- 
lief that  this  inadequacy  or  delay  in  recovery  is  due  to  want 
of  recognition  by  the  surgeon  of  all  that  is  needed  in  the 
technical  part  of  the  operation.  My  colleagues  on  the  staff  of 
the  Second  Northern  Hospital  in  Leeds  are  obtaining  results 
which  in  rapidity  and  completeness  would  have  been  thought 
impossible  before  the  war. 

There  is  rarely  any  difficulty  in  obtaining  accuracy  of  ap- 
position without  tension.  If,  however,  the  nerve  ends  can  not 
readily  be  brought  together,  various  procedures  may  be  adopted 
to  shorten  the  course  of  the  nerve.  The  nerve  may  be  dis- 
located from  its  bed  and  laid  in  a  new  and  shorter  line.  The 
ulnar  nerve,  for  example,  may  be  brought  to  the  front  of  the 
inner  condyle.  Or  flexion  of  the  limb  may  be  enough  to  allow 
of  easy  approximation.  In  the  case  of  the  median  nerve  divided 
low  in  the  forearm,  flexion  of  the  wrist  will  give  an  inch  or 
more  additional  reach.  In  other  cases  the  limb  may  be  short- 
ened by  removing  an  inch  or  two  of  bone.  It  is  desirable  to 
avoid  a  subcutaneous  course  in  all  transferences  to  new  posi- 
tions. The  nerve  after  suture  should  be  brought  to  lie  in  a 
bed  of  healthy  tissue.  It  must  be  placed  between  muscles,  and 
away  from  all  contact  with  new  connective  tissue,  which  will 
adhere  to  it,  and  hinder  its  union,  or  cripple  its  subsequent  action. 
It  has  been  the  fashion  with  many  surgeons  to  surround  the 
sutured  nerve  with  some  material  supposed  to  have  protective 
virtues.  A  piece  of  a  vein,  the  saphenous  for  example,  is 
threaded  over  the  upper  cut  end  of  the  nerve  before  suture,  and 
after  these  ends  are  approximated  the  vein  is  drawn  downward 
and  made  to  surround  the  line  of  suture.  In  other  cases,  a 
piece  of  fat  dissected  from  near  the  wound,  or  from  another 


ABSTRACTS   OF   WAR   SURGERY  37'J 

part,  is  wrapped  round  the  nerve:  fat  being  supposed  to  be 
capable  of  insulating  the  nerve  in  its  new  position:  or  a  layer 
of  fascia  may  be  used,  or  a  piece  of  Cargile  membrane.  The 
value  of  all  such  methods  is  open  to  serious  question;  it  is 
certain  that  they  are  sometimes  harmful,  it  is  doubtful  if  they 
ever  help.  They  prevent  access  of  blood  to  the  nerve  by  new 
channels,  they  cause  adhesions  and  compression  of  the  nerve 
and  at  times  they  are  discharged  from  the  wound  almost  un- 
altered. It  is  better  to  avoid  such  membranes,  and  to  be  con- 
tent with  insuring  that  the  nerve  is  laid  along  a  path  of  unin- 
jured tissues.  Where  end-to-end  suture  is  impossible  a  variety 
of  other  procedures  may  be  attempted.  A  nerve  graft,  taken 
from  a  neighboring  cutaneous  nerve,  from  the  radial,  the  inter- 
nal cutaneous  of  the  thigh,  or  an  intercostal  nerve  may  be  used. 
Nerve-anastomosis  has  been  tried  in  a  number  of  cases.  The 
divided  ends  of  a  nerve  are  implanted  into  the  side  of  a  near- 
lying  nerve;  the  ulnar  into  the  median  for  example.  This  has 
been  done  both  with,  and  without,  section  of  the  nerve  fibers 
of  the  intact  nerve.  All  such  procedures  are  worthless  and  can 
not  be  too  strongly  condemned. 

Happily  the  resources  of  surgery  are  not  at  an  end  in  all 
cases  where  union  of  divided  nerves  is  impossible.  Tendon 
transplantation,  especially  in  the  case  of  the  musculospiral 
nerve,  and  the  posterior  interosseous,  gives  results  which  in 
point  of  function  are  almost  as  good  as  those  which  come  from 
nerve  suture,  and  in  point  of  time  are  much  quicker. 

In  those  cases  where  the  nerve  is  partly  divided,  strands  of 
intact  fibers  still  remaining,  the  severed  fibers  are  united  in 
the  same  careful  way,  and  the  normal  strand  of  the  nerve  bent 
upon  itself  so  as  to  allow  easy  approximation  of  the  cut  por- 
tions of  the  nerve.  In  perhaps  the  majority  of  operations  upon 
nerves,  there  is  no  division  of  fibers,  but  a  length  of  the  nerve 
is  embedded  in  dense  fibrous  tissue.  These  cases  give  most 
excellent  results.  The  fibrous  tissue  which  so  intimately  sur- 
rounds the  nerve  is  dissected  away  little  by  little.  The  nerve 
when  first  freed  is  seen  to  be  white  and  shrunken;  but  within 
a  few  minutes  it  expands  and  takes  on  its  normal  color. 

After-treatment. — (1)  Postural. — In  those  cases  where  flexion 
of  a  joint  has  been  necessary  to  allow  approximation  of  the 
cut  ends  of  nerves  the  position  is  maintained  for  a  period  of 
six  weeks.  By  this  time  union  of  the  severed  ends  is  probably 
well  advanced.  Extension  by  slow  and  most  cautious  degrees 
is  then  begun.    If  the  knee  has  been  flexed  to  allow  the  sciatic 


380  ABSTRACTS  OF  WAR  SURGERY 

nerve  to  be  united,  the  patient  can  walk  with  a  boot  and  leg 
irons,  keeping  the  position  unaltered  for  say  two  months. 
Wherever  possible  a  splint  is  applied  which  produces  a  "relaxa- 
tion position."  In  the  case  of  the  median  and  the  ulnar  this 
is  difficult,  but  is  best  secured  by  molding  a  "ball  splint"  to 
the  hand  of  the  patient.  Every  such  splint  must  be  made  for 
the  individual.  In  the  case  of  the  musculospiral,  it  is  very 
simple.  The  "cock-up"  splint  designed  by  Colonel  Sir  Robert 
Jones  is  excellent,  if  the  lesion  of  the  nerve  is  below  the  branch 
to  the  supinator.  It  maintains  hyperextension  of  the  wrist,  and 
reaching  only  to  the  heads  of  the  metacarpal  bone  it  allows  a 
forward  bend  of  the  metacarpophalangeal  articulations.  The 
thumb  lies  forward  and  a  little  inward,  so  that  the  position  of 
the  whole  hand  is  very  much  that  assumed  when  a  bottle  is 
grasped.  If  the  lesion  is  above  the  nerve  to  the  supinator  brevis, 
it  is  essential  that  this  muscle  also  should  be  relaxed.  For  this 
purpose  Cuthbert  Morton  has  devised  a  splint  which  retains  the 
forearm  and  hand  in  supination  while  the  wrist  is  fully  ex- 
tended, the  fingers  being  at  the  same  time  kept  in  the  bottle- 
grasping  position. 

2.  Massage  and  Electrical  Treatment. — These  measures  are  re- 
started about  two  weeks  after  operation  with  all  due  precau- 
tions and  safeguards.  If  a  splint  has  been  applied  to  secure 
the  "relaxation  position"  it  must  not  be  removed.  Indeed,  not 
for  one  moment  at  any  time  must  paralyzed  muscles  be  stretched. 
An  overstretching  of  a  few  minutes  may  call  for  diligent  treat- 
ment of  many  weeks  before  the  harm  is  undone. 

Results. — Our  records  are  as  yet  necessarily  incomplete.  Re- 
covery in  the  case  of  the  musculospiral  has  begun  within  9 
weeks;  in  the  case  of  the  ulnar  within  3y2  months;  in  the  case 
of  the  median  in  4  to  5  months.  In  one  case  of  division  of  the 
inner  cord  of  the  brachial  plexus,  recovery  in  all  anesthetic 
areas,  and  a  degree  of  recovery  in  all  muscles,  occurred  within 
5  months.  Recovery  in  the  case  of  the  sciatic  nerve  is  slower. 
Something  depends,  it  is  sometimes  said,  upon  the  length  of 
time  elapsing  between  division  of  the  nerve  and  its  suture.  My 
colleague,  Captain  Richardson,  has,  however,  united  the  ends 
of  an  ulnar  nerve  cut  across  15  years  before  and  signs  of  re- 
turning function  were  seen  in  about  four  months.  The  dura- 
tion of  the  disability  is,  therefore,  no  bar  to  successful  nerve 
repair. 

The  functions  return  usually  in  the  following  order  :  (1)  trophic 
and   vasomotor   function,    (2)  deep    sensibility,    (3)  tactile    dis- 


ABSTRACTS  OF  WAR  SURGERY  381 

crimination  and  localization,  (4)  motor  power,  (5)  cotton  wool 
sensation. 

Perfect  restoration  of  function  has  been  most  nearly  ap- 
proached in  the  case  of  the  musculospiral  nerve.  In  other 
nerves  with  more  complex  distribution,  perfect  recovery  will 
depend  upon  a  recognition  of  the  functional  localization  within 
the  nerve  trunk,  in  addition  to  the  most  scrupulous  observance 
of  all  those  technical  details  without  which  there  will  always 
be  something  less  than  perfection. 

In  the  diagnosis  and  treatment  of  an  organic  lesion  of  a 
nerve,  it  should  never  be  forgotten  that  there  may  be  super- 
added a  functional  disability.  It  is  advisable  at  every  stage  to 
get  rid  of  the  functional  in  order  to  properly  appreciate  the 
organic.  This  is  particularly  important  when  the  organic 
lesion  is  well  on  the  way  to  recovery.  Thus,  in  a  recovering 
lesion  of  the  inner  cord  of  the  brachial  plexus,  it  may  be  pos- 
sible for  the  fingers  to  be  flexed  until  reeducation  has  trained 
the  laggard  muscles  into  obeying  orders  from  headquarters. 

THE  TREATMENT  OF  PERIPHERAL  NERVE  INJURIES.— 

Rev.  of  War  Surg,  and  Med.,  May,  1918,  i,  No.  3. 

Of  all  the  surgical  specialties,  none  have  had  graver  prob- 
lems in  diagnosis  and  therapy  than  those  which  have  fallen  to 
the  lot  of  neurological  surgeons  during  this  war.  It  is  unhap- 
pily true  that  most  of  the  moot  points,  vital  as  they  are,  will 
have  to  wait  till  time  deferred  before  certain  judgment  may 
be  practiced.  It  is  none  the  less  necessary,  however,  to  take 
inventories  now  and  then,  in  order  to  estimate,  if  not  actually 
to  measure,  progress.  The  following  report  to  the  Surgeon 
General  enables  the  reader  to  trace  the  problem  of  the  treat- 
ment of  peripheral  nerve  injur y  from  the  beginning  of  the  war 
down  to  date : 

Preliminary  Treatment. — Every  wound  or  injury  of  peripher- 
al nerves  should  be  recognized  at  the  earliest  possible  time. 
Areas  of  anesthesia,  hypotonia,  loss  of  reflexes,  trophic  changes, 
atrophy,  and  characteristic  attitudes  serve  as  evidence  of  nerve 
lesion.  In  all  cases  treatment  should  begin  at  once.  Lyle  has 
emphasized  this  in  the  statement :  "  It  is  imperative,  whether 
nerve  is  divided  or  not,  that  the  paralyzed  muscles  be  relaxed 
and  protected  from  strain  by  a  suitable  apparatus.  Under  no 
circumstances  must  this  be  deferred  as  an  after-treatment." 
The  postural  prophylaxis  begins  with  receipt  of  wound  and  con- 


382  ABSTRACTS  OF  WAR  SURGERY 

timies  after  operation  until  voluntary  movement  is  resumed. 
Frequent  examples  of  violation  of  this  principle  are  too  com- 
mon. On  the  one  hand  support  of  paralyzed  muscles  is  neg- 
lected; the  limb  drops  and  this  results  in  stretching  of  the 
paralyzed  muscles  and  tendon  and  an  almost  hopeless  condi- 
tion. On  the  other  hand,  splints  continually  applied  holding 
in  a  fixed  position  both  paralyzed  muscles  and  those  not  par- 
alyzed result  in  extensive  joint  and  tendon  lesions.  In  this 
way  fascial,  tendon,  and  joint  fixation  occur.  Not  only  should 
no  overstretching  of  paralyzed  muscles  be  permitted,  but  per- 
manent fixation  of  tendon  and  joints  should  be  prevented  by 
early  massage. 

Von  Lorentz  urges  early  postural  treatment  and  gives  as  an 
additional  argument  the  statement  that  overstretching,  in  the 
case  of  nerve  section,  causes  the  end  of  the  nerve  to  separate 
to  so  great  a  degree  that  they  can  not  be  gotten  together  at 
operation.  The  massage  of  inflamed  tissues  must  be  avoided. 
With  the  disappearance  of  inflammation  active  movement  and 
massage  is  suitable. 

Borchardt  emphasized  early  movement,  massage,  and  elec- 
trical treatment.  Even  in  seemingly  hopeless  cases  massage 
seems  to  be  of  use,  and  sometimes  the  final  result  is  good.  Tinel 
urges  massage,  even  in  painful  cases.  Some  of  these  contrac- 
tures are  caused  by  infection.  "With  extensive  infection  dam- 
age is  done  that  can  not  easily  be  corrected,  and  early  massage 
is  impossible. 

Every  surgeon  should  know  the  nerve  supply  of  the  various 
groups  of  muscles,  so  as  to  be  able  intelligently  to  apply  post- 
ural splints.  Without  such  knowledge  any  explanation  is 
difficult;  with  such  knowledge  it  is  superfluous. 

Lyle's  teachings  are  of  the  utmost  value  and  make  possible 
a  successful  outcome  to  surgical  procedure.  Many  of  the  numer- 
ous contributors  to  literature  have  passed  lightly  over,  or  neg- 
lected entirely,  the  question  of  postural  treatment  and  mas- 
sage. Jones,  Tubby,  and  Lyle  are  noted  exceptions  to  this.  In 
the  light  of  the  Canadian  returned  soldiers  this  phase  of  the 
question  would  seem  to  be  of  fundamental  importance.  As  an 
after-treatment,  massage  is  mentioned  by  Nonne  and  Thoele. 

Indications  for  Operation. — Clinical  manifestations  of  nerve 
disturbances  have  as  a  basis,  functional  causes,  physiological 
interruption,  and  anatomic  interruption.  Separation  into  these 
three  classes  gives  a  basis  for  surgical  interference,  but  diag- 
nosis is  by  no  means  easy.     Operation  is  applicable  to  anatomic 


ABSTRACTS  OF  WAR  SURGERY  383 

interruptions  and  to  physiological  interruptions  when  due  to 
pressure  of  scar.  In  many  cases  distinction  is  made  clear  only  by 
observation  and  time. 

In  functional  cases  no  pathology  can  be  described.  Func- 
tional cases  give  normal  electrical  reactions  and  are  distinct 
from  physiological  interruption,  although  in  cases  of  the  latter 
definite  pathology  may  escape  observation  or  may  have  disap- 
peared at  the  time  of  the  observation.  Tubby  terms  physiolog- 
ical interruptions  "concussions  of  the  nerve."  It  is  damage 
done  to  a  nerve  trunk  without  actual  destruction  of  axis  cylin- 
ders, and  the  damage  may  consist  of  an  effusion  of  blood  be- 
tween the  fibers  following  compression  of  nerve  against  bone, 
caused  by  rapid  passage  of  foreign  body  in  the  immediate 
neighborhood  of  the  nerve.  In  other  cases  the  actual  lesion 
may  not  amount  to  hemorrhage  but  to  a  temporary  anemia. 

Heile  and  Hezel  state  that  if  the  nerve  is  grazed  by  a  bullet, 
an  inflammatory  exudate  may  occur  in  the  nerve,  changing  its 
contour.  "The  diameter  of  the  swollen  nerve  in  extreme  cases 
may  be  three  times  that  of  the  normal  nerve."  In  time  this 
exudate  is  absorbed,  leaving  behind  more  or  less  scar  tissue  and  ad- 
hesions to  the  nerve  sheath.  The  amount  of  connective  tissue 
determines  whether  the  interruption  is  physiological  or  anatom- 
ical. In  addition  it  is  recalled  that  rapid  recovery  usually  fol- 
lows the  liberation  of  nerves  slightly  bound  by  extraneural 
scar  tissue  (Monsaigeon).  Tinel  explains  this  on  the  ground 
of  physiological  interference  of  conductivity  without  occur- 
rence of  Wallerian  degeneration.  These  lesions  can  not  be  dis- 
tinguished clinically  from  those  of  anatomic  interruptions.  Ex- 
cept in  cases  definitely  strangled  with  scar  tissue,  spontaneous 
recovery  may  follow  massage  and  other  nonoperative  remedies. 

A  full  description  of  the  pathology  of  anatomical  separation 
will  be  deferred  to  that  part  of  the  report  devoted  to  "suture." 
Anatomical  interruption  includes  lesions  of  intraneural  scar 
tissue  as  well  as  actual  solution  of  continuity  of  nerve.  Fright 
may  cause  complete  or  partial  interruption.  Unfortunately,  the 
reaction  of  degeneration  is  common  to  both  physiological  and 
anatomical  interruptions.  However,  this  is  usually  partial  and 
incomplete  in  former  conditions.  In  addition,  muscular  tone  in 
physiological  interruptions  is  not  usually  lost,  according  to 
Tinel.  In  case  of  doubt  as  to  neurological  findings  an  expect- 
ant treatment  would  seem  to  be  best.  Tinel  found  that  60  per 
cent  of  nerve  lesions  recover  spontaneously  with  proper  post- 
ural, mechanical,  and  electrical  treatment.     He  states  the  in- 


384  ABSTRACTS  OP  WAR  SURGERY 

dications  for  operation  as  follows:  (1)  Absence  of  regenera- 
tion; (2)  defective,  difficult,  or  partial  regeneration;  (3)  com- 
plete interruption.  Tinel  states  further:  "Because  a  nerve 
fiber  is  incapable  of  excitement  we  can  not  conclude  that  it  is 
not  in  spontaneous  regeneration."  Electrical  excitability  is  a 
late  phenomenon.  The  sensibility  of  nerve  to  pressure,  formica- 
tion, and  return  of  tone  and  paresthesia  are  important  signs. 

Tinel's  syndromes  are  important  to  remember:  (1)  Interrup- 
tion,   (2)   compression,    (3)  irritation,    (4)  regeneration. 

Cassirer  found  only  60  operative  cases  among  240  nerve  in- 
juries and  in  only  15  was  the  nerve  found  severed.  In  litera- 
ture there  seems  to  be  a  great  diversity  of  opinion  as  to  the 
advisability  of  early  operation.  Wilms  makes  exploratory 
operation  to  find  out  the  condition  of  the  nerve  without  wait- 
ing at  all.  He  urges  that  it  is  best  to  operate  before  scar-tis- 
sue changes  have  occurred.  One  fails  to  see  why  scar  tissue 
developing  after  operation  is  not  as  bad  as  or  worse  than 
might  develop  before.  Infection  is  the  main  source  of  scar  tis- 
sue. Thoele  and  Auerbach  also  advise  early  operation.  Thoele 
waits  six  to  eight  weeks  after  healing  where  there  is  partial 
reaction  of  degeneration.  If  reaction  of  degeneration  is  com- 
plete Auerbach  urges  early  operation  if  a  history  of  infection 
does  not  prevent.  In  healed,  formerly  infected  wounds  he 
waits  three  months.  Borchardt  advocates  early  operation.  He 
considers  severe  sensory  disturbances,  trophic  changes,  and 
complete  reactions  of  degeneration  as  indications.  Relying  on 
neurological  examinations  he  has  operated  56  times  and  found 
pathological  conditions  in  all  but  two  cases. 

Carrel,  in  connection  with  Carrel-Dakin  treatment,  advised 
immediate  suture  of  nerves  in  fresh  injuries,  as  nerves  resist 
infection  well,  and  excessive  retraction  of  the  nerves  is  by  this 
procedure  prevented,  so  that  subsequent  operation  is  easy. 
Nonne,  in  presence  of  reaction  of  degeneration  and  anesthesia, 
does  not  urge  immediate  operation,  but  waits  six  or  eight  weeks. 
Ferrand  says  operations  should  never  be  undertaken  within 
the  first  two  months  and  sometimes  urges  waiting  even  longer. 
He  advises  operation  in  cases  of  compression  or  interruption, 
but  not  in  partial  lesions.  Hoffman  insists  on  waiting  for  com- 
plete healing  of  the  wound.  He  emphasizes  the  persistence  of 
bacteria  in  the  tissues  after  healing,  especially  in  fracture 
cases,  and  therefore  urges  a  delay  of  from  six  to  nine  months. 
The  persistence  of  bacteria  in  apparently  healed  wounds  is  re- 
markable.    Gallie  encountered  a  small  abscess  with  living  bac- 


ABSTRACTS  OF  WAR  SURGERY  385 

teria  in  a  wound  that  was  apparently  healed  over  four  months. 
Bone  has  been  known  to  harbor  infection  for  a  longer  time. 
The  tendency  of  old  wounds  to  suppurate  after  long  quiescence 
and  apparent  healing  is  but  another  manifestation  of  this.  Stop- 
ford  considers  cases  surgical  if  there  is  no  improvement  after 
four  to  eight  months.  He  also  operates  when  improvement  is 
checked  or  there  are  retrograde  symptoms.  Moynihan  oper- 
ates in  complete  division  of  the  nerve  in  cases  of  incomplete 
divisions  or  arrested  improvement,  and  in  causalgia.  He  waits 
three  months  after  healing  in  bone  cases  and  one  month  in 
other  cases.  He  urges  the  correction  of  joint  ankylosis  before 
operating  on  nerves — "Do  not  operate  until  healing  is  complete, 
else  infection  will  flare  up."  As  an  additional  argument  for 
delay,  it  may  be  stated  that  cases  treated  with  massage  give 
their  first  signs  of  regeneration  in  from  two  to  four  months,  and 
in  one  case  in  nine  months. 

Preparation  of  Field. — The  operative  field  must  be  prepared 
according  to  approved  aseptic  rules,  and  then  the  limb  must 
be  draped  so  that  at  any  stage  of  the  operation  it  may  be  moved 
into  any  desired  position. 

Use  of  Tourniquet. — The  tourniquet  gives  a  dry  field.  When 
it  is  used  the  tissues  rapidly  dry  out  from  exposure  to  the  air 
and  unless  prevented  from  doing  so  will  suffer  damage.  Anemia 
of  a  limb  lasting  over  two  hours  is  hazardous.  The  pressure 
of  the  tourniquet  on  the  nerve  for  a  period  of  time  greater  than 
two  hours  may  cause  paralysis.  Intraneural  bleeding  might  be 
masked  by  a  tourniquet  and  overlooked.  In  addition  hemor- 
rhage and  hematoma  are  complications  that  sometimes  occur 
after  artificial  anemia.  Shiffbauer,  Thoele,  Grosse,  Lorentz,  and 
Moynihan  condemn  the  tourniquet.  On  the  other  hand  opera- 
tion in  a  bloodless  field  gives  an  opportunity  to  recognize  anato- 
my and  avoids  the  escape  of  blood  into  the  tissues.  Diffuse 
blood  in  the  tissues  interferes. with  healing.  Borchardt,  Gibson, 
and  Hoffman  favor  the  use  of  the  tourniquet. 

Operative  Procedures. — There  are  two  distinct  types  of  opera- 
tive procedure:  (1)  Neurolysis,  or  freeing  of  nerves  bound  by 
extraneural  scar  tissue  (the  so-called  simple  compression  of 
Tinel).  (2)  Repair  of  complete  anatomical  division.  The 
operation  of  neurolysis  is  a  simple  procedure  consisting  of  free- 
ing nerves  from  extraneous  scar  tissue.  With  operation  in 
aseptic  field,  with  proper  control  of  hemorrhage  and  suitable 
after-treatments,  the  adhesions  have  the  likelihood  of  not  re- 
turning; or  their  return  is  benign.     Liberation  is  ineffective  in 


386  ABSTRACTS  OF  WAR  SURGERY 

intraneural  nerve  scar,  "keloid"  or  severe  lesion  of  nerve 
sheath  involving  the  nerve  itself.  Tinel  states  that  in  such 
cases,  either  suture  or  noninterference  is  indicated.  In  addi- 
tion to  simple  neurolysis,  Grosse,  Auerbach,  Schiffbauer,  and 
Ferrand  transplanted  liberated  nerves  to  new  muscle  bed.  Hoff- 
man criticises  this  procedure  and  urges  in  its  place  the  invest- 
ment of  the  suture  with  grafts  of  fascia.  These  must  be  large 
and  loose.  Stoffel,  in  his  "Review  of  Neurolysis"  says,  "Re- 
sults are  bad  after  simple  nerve  liberation  when  no  wrapping 
has  been  done."  He  urges  the  use  of  calves'  veins  and  peri- 
toneum. Bittorf  states  that  fat  sheaths  become  adherent.  He 
uses  formalized  calves'  arteries  and  celluloid  tubes.  Borchardt, 
after  two  years,  still  clings  to  his  fascial  graft.  Tuffier  and 
Dumas,  at  the  beginning  of  the  war,  used  investments  of  fascia. 
Heile  and  Hezel  use  rubber  tubes.  Steinhall  condemns  these 
tubes  and  shows  cases  where  they  have  failed.  Thoele  believes 
sheaths  contract  and  strangulate  the  nerves.  He  advocates 
covering  the  nerves  with  normal  attached  fat  and  keeping  the 
suture  lines  from  crushing  the  bare  nerves.  Tinel  condemns 
investing  material  of  any  kind.  Moynihan  does  not  approve  of 
any  form  of  material  about  the  suture  line. 

Nerve  Suture. — Complete  anatomical  division  may  be  due  to 
section  and  absolute  separation  of  the  ends  of  nerve  or  it  may 
be  due  to  intraneural  connective  tissue,  either  combined 
with  extraneural  tissue  or  not  combined.  This  condi- 
tion calls  for  cutting  through  the  nerve  and  reunion  by  suture. 
Following  gunshot  injuries  the  nerves  may  be  found  either  con- 
tinuous or  divided,  but  completely  fused  in  a  great  mass  of 
general  scar  tissue.  The  scar  may  be  extraneural,  it  may  in- 
volve the  sheath,  it  may  appear  as  an  intraneural  diffuse  or 
massed  scar  tissue.  As  much  as  4  inches  of  this  type  of  de- 
struction may  be  present.  If  there  is  complete  separation, 
usually  a  neuroma  occurs  on  either  segment.  To  allow  access 
to  such  damaged  areas  very  wide  dissection  must  be  practiced, 
start  being  made  in  normal  regions  to  either  side  of  damaged 
area.  Intimate  anatomical  knowledge  is  necessary.  In  mak- 
ing these  dissections  the  nerve  should  not  be  handled.  Tissues 
are  best  retracted  away  from  the  nerve.  When  necessary  to 
retract  the  nerve  this  should  be  done  with  tape  (Thoele)  or  by 
a  rubber  band  (Jones).  Usually  the  proximal  portion  of  the 
nerve  will  be  found  to  terminate  in  a  large  ball  of  scar  tis- 
sue. This  sometimes  is  an  inch  in  diameter  and  may  be  more 
or  less   connected  with  surrounding  structures.     Such  a  mass 


ABSTRACTS  OF  WAR  SURGERY  387 

differs  in  no  way  from  the  ordinary  amputation  neuroma.  The 
distal  segment  may  also  present  a  similar  clubbed  end.  These 
masses  are  usually  composed  either  entirely  or  to  a  great  de- 
gree of  connective  tissue.  Sometimes  the  connective  tissue  ap- 
pears as  a  tumorlike  mass.  At  other  times  the  axis  cylinders 
try  to  penetrate  the  scar  tissue,  but  are  overwhelmed.  When 
the  nerve  is  freed  examination  is  made  to  see  how  much  is 
functional  and  how  much  is  scar  tissue.  The  condition  of  the 
nerve  may  be  ascertained  by  incising  the  sheath  and  examin- 
ing for  fasciculi.  These  have  an  anglewormlike  appearance.  It 
is  customary  to  make  repeated  transverse  sections  of  the 
neuroma  until  the  cross  section  presents  a  normal  appearance, 
both  in  the  distal  and  proximal  portions.  The  normal  nerve 
presents  fasciculi  close  together  with  good  blood  supply.  De- 
lorme  repeatedly  resects  until  he  gets  good  nerve.  Borchardt 
also  resects.  He  sometimes  sutures  the  nerve  without  remov- 
ing all  of  the  scar-bearing  tissue  if  it  is  necessary  to  do  this  to 
get  approximation.  Dumas  attempted  to  bridge  defects  in 
nerve  with  scar  tissue  and  had  100  per  cent  failures.  Wilms  ap- 
proximates normal  nerves  but  uses  scar  as  a  splint. 

Blood  Supply  of  the  Nerves. — The  blood  supply  of  the  nerves 
is  important  both  from  a  question  of  viability  and  the  question 
of  hemostasis.  This  has  been  emphasized  by  Grosse.  Dumas 
raised  the  scar  in  proximity  to  the  nerve  as  the  best  way  to 
maintain  the  blood  supply.  Nerves  have  rather  abundant  blood 
supply  and  will  frequently  bleed  on  section.  This  vascularity 
is  largely  longitudinal,  but  repeated  reinforcement  from  the 
periphery  is  received.  Fifteen  inches  of  the  nerve  can  be 
stripped  loose  and  yet  retain  enough  circulation  to  give  capil- 
lary oozing  when  cut.  Whether  this  is  sufficient  to  maintain 
life  or  not  experiments  will  have  to  prove.  Moynihan  cautions 
against  devascularizing  the  nerves.  The  control  of  intraneural 
hemorrhage  is  important.  This  has  been  emphasized  by  Bor- 
chardt, Schiffbauer,  Edinger,  and  Lewis.  Hemorrhage  some- 
times has  to  be  controlled  by  the  use  of  mosquito  forceps  and 
very  fine  ligatures.  This  is  especially  difficult  to  do  without 
injury  to  the  nerve  fasciculi  as  the  minute  vessels  tend  to  re- 
tract into  the  nerve.  Squeezing  the  nerve  gently  with  the 
fingers  makes  the  blood  vessel  stand  out  like  a  comedo.  The 
use  of  adrenalin  is  not  permissible. 

Approximation. — All  operators  agree  that  the  ends  of  the 
nerve,  after  being  freed  from  scar  tissue,  had  best  be  approxi- 


388  ABSTRACTS  OF  WAR  SURGERY 

mated.  Tinel  says  this  is  the  only  way.  This  may  be  brought 
about  by  bending  the  joint,  as  indicated  by  Delorme.  A  nerve 
gap  of  2  inches  may  be  overcome  by  moving  the  limb.  Bor- 
chardt  emphasized  the  importance  of  flexion.  Heile  and  Hezel 
state  that  gaps  up  to  6  centimeters  may  be  closed  by  flexion  and 
liberation  of  the  nerve.  Sharp  states  that  posture  can  supply 
only  4  centimeters  of  gap.  The  effect  on  the  nerve  by  bending 
joints  is  increased  by  mobilizing  the  nerve,  especially  in  case 
of  the  ulnar.  This  may  mean  complete  dissection  for  15  inches, 
a  questionable  procedure,  because  important  motor  branches 
have  to  be  severed  and  circulation  is  jeopardized.  Such  mobili- 
zation might  correct  a  gap  of  4  inches. 

Fascicular  Orientation. — The  bringing  together  of  a  nerve 
without  twisting  or  altering  its  anatomical  relationship  is  im- 
portant. Stoffel  has  mapped  out  a  topographical  arrangement 
of  the  fasciculi.  These  are  separated  into  groups  with  specific 
functions.  In  making  suture  the  topography  must  be  con- 
sidered. Tinel  and  Thoele  indorse  this  principle.  Heile  and 
Hezel  rather  minimize  the  importance  of  such  orientation. 
They  use  for  argument  the  good  results  obtained  when  nerves, 
in  former  times,  were  united  haphazard.  Borchardt  says  cor- 
responding nerve  tracts  must  be  brought  into  apposition. 

Suture  Material. — In  small  nerves  Sherren  advocated  one 
through-and-through  suture  of  chromic  catgut.  This  does  not 
seem  to  be  applicable  to  the  suture  of  the  larger  nerves.  Gibson, 
following  Thoele,  uses  four  sutures  of  plain  catgut  through  nerve 
sheath  only.  Moynihan  advocates  nerve  sheath  suture.  Bonnet 
compares  neurilemma  to  peritoneum  in  regard  to  suture.  Heile 
and  Hezel  at  first  used  silk,  but  changed  later  to  catgut.  Inter- 
position of  blood  clot  in  suture  line  will  deflect  axis  cylinders  ac- 
cording to  Edinger.  The  least  crushing  at  the  point  of  suture  will 
cause  fasciculi  to  turn  out.  The  use  of  silk  advocated  in  Schiff- 
bauer  seems  unnecessary,  for  healing  in  nerve  is  rapid.  Union 
of  cut  nerves,  according  to  Dustin,  is  fairly  well  advanced  in  four 
days.  Tension  must  be  avoided  in  suture,  as  the  very  slightest 
traction  on  suture  line  renders  proper  coaptation  impossible. 

Suture  Line. — The  junction  is  important.  Thoele  has  urged 
preserving  the  fasciculi  intact,  when  damage  does  not  extend 
through  entire  section  of  nerve.  Gibson  is  utilizing  this  principle 
with  remarkably  good  results  on  partial  lesions.  He  cuts  diagon- 
ally through  the  damaged  nerve,  leaving  a  bridge  of  normal 
nerve  so  that  the  suture  line  crosses  the  nerve  at  oblique  angle. 
From  the  good  results  obtained  in  this  case  Gibson  was  led  to 


ABSTRACTS  OF  WAR  SURGERY  389 

cut  all  his  nerves  on  the  bevel  so  as  to  bring  about  a  large  area. 
Heile  and  Hezel  speak  of  slitting  the  nerve  sheath  after  suture 
to  prevent  an  accumulation  of  exudate  and  avoid  damage  that 
might  result  from  pressure. 

Bridging  Gaps  in  a  Nerve. — When,  by  flexing  the  limb,  it  is 
impossible  to  secure  coaptation  of  the  cut  ends  of  the  nerve,  some 
other  device  must  be  resorted  to.  Even  shortening  of  the  bone 
has  been  suggested.  The  more  logical  remedies  seem  to  be  free 
grafts  of  nerve  or  use  of  hollow  tubes  intended  for  the  down- 
growth  of  axis  cylinders. 

Fascial  Tubes. — The  use  of  the  fascial  tube  about  the  nerve 
lying  in  scar  tissue  is  a  question  concerning  which  authorities 
differ.  This  has  already  been  discussed.  Lewis  suggested  the 
use  of  hollow  tubes  of  fatty  fascia  connecting  the  ends  of  the 
nerve  when  they  could  not  be  approximated.  This  procedure 
works  admirably  in  experimental  work.  Its  place  in  surgery, 
according  to  Lewis,  is  not  definitely  established.  The  author  of 
this  report  saw  one  case  of  beginning  motor  function  where  this 
had  been  done.  Col.  Starr  states  that  isolated  cases  done  with 
fatty  fascial  graft  were  successful  but  that  there  were  many 
failures.  He  cited  two  instances  where  grafts  were  found  to  be 
mere  cords  of  tissue  on  subsequent  operations.  Tubes  of  various 
kinds  have  been  suggested.  Edinger  says  human  fibers  grow 
best  when  the  two  united  ends  of  the  nerve  are  inserted  into  an 
agar  filled  artery.  Cases  operated  upon  in  this  way  have  shown 
reduced  areas  of  anesthesia  or  return  of  reflexes  within  a  very 
short  time.  Heile  and  Hezel  use  rubber  tubes  employing  nonvul- 
canized  pure  rubber  tubes.  This  is  condemned  by  Steinhall,  but 
the  same  idea  has  been  suggested  by  St.  Martin. 

Nerve  Grafting. — The  oldest  type  of  nerve  grafting  to  fill  in  a 
gap  is  that  of  Letievant.  This  author  operated  successfully  on 
no  case  in  that  manner.  Gratzel  still  used  this  method,  calling 
attention  to  the  importance  of  using  the  distal  portion  of  the 
nerve  for  the  graft  and  covering  the  entire  graft  with  a  tube  of 
fascia.  Thoele  speaks  of  this  procedure  as  "Peripheral  Grafts." 
Keene  and  Loebker,  independently,  advocated  a  free  graft  of 
the  radial  in  wide  defects  of  musculospiral  nerve.  This  method 
has  been  brought  to  our  attention  and  given  an  experimental 
foundation  by  the  work  of  Ingebrigtsen,  who  has  contributed  a 
number  of  articles  on  this  subject.  In  one  of  the  early  ones  he 
shows  that  when  the  bits  of  nerve  are  cultivated  in  vitro,  the 
axis  cylinders  do  not  grow,  but  growth  does  occur  in  the  syncytial 


390  ABSTRACTS  OF  WAR  SURGERY 

cells  of  Schwann.  Axis  cylinders  will  grow  in  vitro  from  nerve 
cells,  but  have  no  independent  power  of  growth.  In  a  subse- 
quent paper  he  shows  that  autogenous  grafts  undergo  Wallerian 
degeneration  and  serve  as  a  scaffolding  for  new  axis  cylinders. 
In  this  connection  one  recalls  Murphy's  neurotropism.  Inge- 
brigtsen  believes  that  free  grafts  are  feasible  and  supports  his 
contention  by  a  series  of  animal  experiments  and  review  of  the 
literature  of  nerve  grafts.  He  recommends  the  use  of  intercostal 
nerves  for  free  grafts.  Sicard  says  where  impossible  to  do  end- 
to-end  suture  to  use  nerve  grafts.  Moynihan  does  not  approve 
of  free  grafts.  Lorentz,  Nonne,  and  Thoele  mention  nerve  graft- 
ing as  possible.  Gratyl  states  that  66  per  cent  of  his  successful 
cases  were  done  by  this  method,  while  Heinemann  gives  70  per 
cent  as  his  figure.  Tinel  describes  nerve  grafting  as  the  only 
legitimate  operation  for  bridging  gaps  when  done  as  recorded  by 
Dejerine  and  Mouzon.  One  objection  to  nerve  grafting  seems 
to  be  the  disparity  in  size  between  the  nerves  to  be  used  as  grafts, 
and  the  nerves  that  are  to  be  grafted.  Only  small  nerves  can  be 
sacrificed  and  these  serve  only  as  slender  threads  between  the 
cut  ends  of  the  large  motor  nerves.  The  supply  of  material  is 
practically  limited  to  the  radial  or  intercostal  nerves. 

Treatment  of  Painful  Cases. — Kaiser,  in  cases  of  neuralgia  and 
neuritis,  urges  use  of  hot  air,  hot  bath,  massage,  electrical  and 
postural  treatment  so  as  to  relieve  tension  of  the  nerves.  Sicard 
mentions  section  and  suture  of  nerve.  In  the  localized  lesion  he 
states  this  is  of  value,  but  is  useless  in  true  neuritis.  To  relieve 
pain,  injections  of  60  per  cent  alcohol  have  been  recommended 
by  the  same  author.  Two  cubic  centimeters  are  used.  Ionization 
with  salicylate  also  has  been  suggested. 

After-treatment. — In  case  distance  has  to  be  regained  from  loss 
of  nerve  substance,  this  is  usually  overcome  by  flexing  the  limb. 
When  so  flexed  the  limb  must  be  immobilized  for  six  weeks,  and 
then  gradually  extended.  This  immobilization  is  mentioned  by 
Lorentz,  but  is  generally  discarded,  although  on  absolutely 
necessary  procedure.  Where  grafts  are  used  and  there  is  no 
tension  on  the  nerve,  mobilization  is  used  to  a  much  less  degree. 

Postural,  mechanical,  and  electrical  treatment  should  be  car- 
ried out  on  every  operative  nerve  lesion.  It  is  remarkable  to  see 
how  contractures  to  tendons  and  joints  are  made  to  lessen  by 
gentle  massage  and  gentle  mechanical  manipulation,  hydrothera- 
peutic  treatment,  ionization,  and  electricity.  The  straightening 
of  bent  limbs  may  be  done  by  plaster  casts  and  wedges.    Forcible 


ABSTRACTS    OF   WAR  SURGERY  391 

tearing  up  of  scar  tissue  in  tendons  or  joints  should  be  avoided. 
Elastic  traction  with  a  variety  of  splints  is  sometimes  used.  With 
the  return  of  voluntary  movement  gymnastic  and  reeducational 
exercises  are  employed. 

THE    AFTER-CARE    OF    NERVE    INJURIES.— Rev.    of    War 
Surg,  and  Med.,  May,  1918,  i,  No.  3. 

The  preceding  report  has  emphasized  the  absolute  necessity  of 
instituting  intelligent  after-care  in  all  instances  of  nerve  injury. 
The  following  report  to  the  Surgeon  General  elaborates  this  topic : 

The  after-care  of  nerve  injuries  involves  two  problems :  first,  the 
care  of  freshly  wounded  and  postoperative  cases;  second,  the 
care  of  late  neglected  cases  where  muscular  contraction  has  taken 
place  and  deformity  has  already  resulted.  In  one  case  treatment  is 
preventive,  in  the  other  corrective.  Many  neglected  cases  may  re- 
quire secondary  operative  procedures.  This  paper  is  concerned 
with  the  first  class  of  cases  and  those  of  the  second  class  which  are 
capable  of  correction  by  mechanical  means  alone. 

Types  of  Injury. — Nerves  may  be  completely  or  partially  cut 
or  torn  across ;  so  seriously  bruised  that  function  is  interrupted  tem- 
porarily or  permanently ;  strangulated  by  pressure  from  contracted 
scar  tissue.  Greater  or  less  degrees  of  paralysis  are  present  ac- 
cording to  the  type  of  injury.  The  ends  of  severed  nerves  may  be 
separated  by  considerable  distances  and  operation  is  often  a  neces- 
sary preliminary.  Postoperative  treatment  does  not  differ  from 
that  required  in  cases  which  do  not  call  for  operation,  and  both 
classes  may  be  grouped  in  considering  after-care. 

Upon  the  interruption  of  nerve  function,  the  following  effects  on 
muscles  are  observed: 

(a)  Tone  and  contractibility  are  lost. 

(b)  Atrophy  sets  in,  due  to — 

1.  Lack  of  voluntary  action. 

2.  Alteration  in  nutrition. 

(c)  Deformity  due  to — 

1.  Stretching  of  the  paralyzed  muscle. 

2.  Contraction  of  healthy  muscle. 

(a)  Muscle  tone  is  a  condition  of  normal  elasticity  inherent  in 
muscle  fiber.  Kept  on  the  stretch  for  a  considerable  period  this 
elasticity  is  lost  in  a  manner  analogous  to  the  loss  of  elasticity  in  an 
overstretched  band  of  rubber.  Voluntary  contraction  is  dependent 
on  nerve  impulse,  and  ceases  on  interruption  of  that  stimulus. 


392  ABSTRACTS  OF  WAR  SURGERY 

(b)  Atrophy  from  disuse  does  not  differ  from  the  wasting  seen 
in  any  prolonged  period  of  inactivity.  There  is  in  addition  an  atro- 
phy due  directly  to  nutritive  changes  from  loss  of  innervation. 
This  affects  muscle,  bone,  and  skin  and  is  apparent  in  the  glossy 
and  often  cyanotic  appearance  of  the  latter. 

(c)  Deformity  occurs  first  as  a  result  of  naccidity  of  paralyzed 
muscle  groups  and  may  be  passively  corrected.  The  habitual  posi- 
tion is  that  produced  by  strong  or  extreme  contraction  of  the  un- 
paralyzed  groups.  If  this  condition  is  allowed  to  continue  without 
treatment,  contractures  occur  in  the  active  muscles  which  prevent 
correction  of  the  deformity.  At  the  same  time  the  paralyzed  mus- 
cles lose  their  tone  and  elasticity.  If  proper  treatment  is  neglected 
during  convalescence  the  nerve  may  recover  but  leave  a  function- 
ally useless  limb  because  of  the  development  of  a  permanent  de- 
formity which  interferes  with  effective  muscular  activity. 

It  is  very  necessary  to  emphasize  the  fact  that  degeneration  be- 
gins immediately  after  injury.  Treatment,  therefore,  should  be  in- 
augurated at  once  and  should  be  continuous.  The  objects  to  be 
achieved  are — 

A.  In  recent  cases — 

1.  Prevention  of  deformity. 

2.  Restoration  of  function. 

B.  In  old,  untreated  cases — 

1.  Correction  of  deformity. 

2.  Development  of  any  remaining  function. 

At  the  outset  the  fact  must  be  faced  that  treatment  is  nearly  al- 
ways prolonged  and  often  discouraging.  The  repair  of  sutured 
nerves  requires,  roughly,  a  year  or  longer,  and  the  surgeon 's  hard- 
est task  is  to  maintain  his  own  and  his  patient's  enthusiasm  during 
the  long  convalescence.  Continuity  of  treatment  is  of  the  utmost 
importance.  Relaxation  for  a  week  may  undo  many  weeks'  con- 
structive work. 

The  methods  of  treatment  employed  are  splinting  and  physical 
theraphy  of  various  kinds. 

Preventive  Splinting. — Rest  in  splints  which  hold  the  part  in 
an  overcorrected  position  is  essential  to  prevent  deformity  in  re- 
cently paralyzed  muscles.  The  required  position  is  one  of  maximum 
overcorrection  with  the  paralyzed  muscles  completely  relaxed  and 
the  active  muscles  held  on  the  stretch  to  overcome  their  tendency 
toward  contracture. 

The  types  of  splints  supplied  by  the  Army  will  be  found  sufficient 
for  many  cases.    Where  preferable,  plaster  of  Paris  splints  may  be 


ABSTRACTS   OF   WAR  SURGERY  31>3 

made  and  are  often  more  adaptable  to  individual  cases.  Splints 
should  be  light  in  weight,  clean,  durable,  easy  to  apply,  and  easily 
removed  for  the  frequent  treatments  usually  required.  The  simpler 
splints  without  mechanical  adjustments  are  far  more  desirable 
where  they  yield  nothing  in  efficiency.  Adjustable  splints  are  some- 
times necessary,  however,  but  their  care  is  more  exacting,  and  in  a 
busy  ward  there  is  danger  of  failure  from  their  use  through  lack  of 
sufficient  attention.  A  rigid  retaining  splint  padded  with  felt,  as 
necessary  for  further  correction,  will  be  found  to  be  most  generally 
useful.  Many  of  the  cases  are  ambulatory,  and  this  fact  must  be 
remembered  in  adapting  a  suitable  appliance. 

Application  of  Splints. — Each  case  will  present  its  individual 
problem  and  calls  for  special  modification  in  the  use  of  splints,  but 
the  following  principles  of  treatment  may  be  of  service  in  ap- 
proaching the  more  frequent  types  of  paralysis : 

Circumflex  Nerve. — Injury  to  the  circumflex  nerve  results  in  del- 
toid paralysis.  The  shoulder  sags  under  the  weight  of  the  arm  and 
power  of  abduction  is  lost.  The  arm  should  be  maintained  in  a 
position  of  abduction  at  right  angles  to  the  body.  To  accomplish 
this,  a  splint  molded  to  the  trunk  is  necessary,  and  it  should  take  its 
bearing  from  the  crest  of  the  ilium  on  the  affected  side,  otherwise  it 
will  slide  downward  when  the  patient  is  in  the  upright  position  and 
lose  its  efficiency.  From  the  body  portion  of  the  splint  a  right- 
angled  armpiece  runs  outward  at  the  axilla  in  a  plane  a  little  an- 
terior to  the  coronal  plane  of  the  body  and  on  this  rests  the  arm. 
The  splint  supplied  for  the  Army — Jones  Abduction  Arm  Splint — 
is  well  adapted  to  this  purpose,  though  plaster  with  wire  armpiece 
is  perhaps  more  commonly  employed  and  is  both  comfortable  and 
efficient. 

Median  Nerve. — Ulnar  Nerve. — These  nerves  supply  the  flexor 
muscles  of  the  forearm.  When  paralyzed  the  tendency  will  be  to- 
ward hyperextension  of  the  hand  on  the  wrist  and  the  fingers  on 
the  hand.  To  offset  this  a  splint  should  be  worn  to  maintain  the  hand 
and  fingers  in  flexion.  A  reversal  short  cock-up  splint  with  a  ball  or 
a  roller  bandage  held  in  the  palm  of  the  hand  will  serve.  A  plaster 
splint  is  more  convenient  and  is  easily  removed  and  replaced  when 
necessary.  Moderate  pronation  should  also  be  provided  on  account 
of  the  loss  of  the  pronator  teres. 

Musculospiral  Nerve. — Loss  of  the  musculospiral  nerve  results  in 
paralysis  of  the  extensors  of  the  arm,  forearm,  and  hand.  The  typi- 
cal sign  is  wrist-drop  and  loss  of  supination.  The  cock-up  splint  is 
serviceable  and  the  arm  should  be  extended  to  relax  the  triceps  and 


394  ABSTRACTS  OF  WAR  SURGERY 

held  in  supination.  Plaster  splints  will  again  be  found  efficient, 
especially  in  maintaining  outward  rotation  of  the  forearm. 

Anterior  Crural  Nerve. — Paralysis  of  the  anterior  crural  gives 
loss  of  power  in  the  anterior  muscles  of  the  thigh  and  the  iliacus  and 
pectineus  which  act  as  thigh  flexors.  Kicking  power  is  absent  and 
contraction  of  the  flexors  of  the  knee  is  to  be  expected.  The  leg 
should  be  held  extended  on  the  thigh  by  means  of  a  straight  pos- 
terior splint  of  wood  or  plaster  of  Paris  or  by  means  of  a  Thomas 
knee  splint,  which  is  light,  easy  to  apply,  and  comfortable  to  wear. 

Sciatic  Nerve. — The  sciatic  supplies  the  muscles  of  the  back  of 
the  leg.  Paralysis  causes  hyper  extension  of  the  knee,  best  guarded 
against  by  a  Thomas  splint.  At  the  same  time  there  is  complete 
paralysis  of  the  muscles  moving  the  foot,  and  retention  at  right 
angles  is  necessary  by  means  of  a  metal  or  plaster  foot  piece. 

The  Internal  Popliteal  Nerve. — As  the  tibial  and  posterior  tibial 
nerve,  this  supplies  the  plantar  flexors  of  the  foot.  Its  paralysis  re- 
sults in  the  deformity  of  calcaneus.  The  foot  must  be  held  in  ex- 
treme plantar  flexion,  and  plaster  of  Paris  is  the  most  effective 
splinting  material. 

The  External  Popliteal  Nerve. — Paralysis  of  the  anterior  tibial 
branch,  supplying  the  dorsal  flexors,  allows  foot-drop  and  eversion. 
This  must  be  met  by  hyperextension  and  inversion  which  may  be 
accomplished  by  bending  upward  the  foot  piece  of  the  Jones  short 
or  long  leg  splint,  but  is  more  commonly  effected  by  means  of  plas- 
ter. Musculocutaneous  nerve  paralysis  produces  inversion  through 
loss  of  the  peroneal  muscles  and  a  position  of  the  foot  approximat- 
ing clubfoot.  Overcorrecting  clubfoot  braces  are  useful,  though 
here  again  plaster  is  more  often  employed. 

The  splints  should  be  comfortable  and  worn  constantly,  save 
when  treatment  is  being  given.  During  the  late  stages  of  con- 
valescence they  should  be  gradually  removed,  at  first  for  short 
periods  during  the  day  when  the  patient  is  allowed  active  exercise. 
They  should  be  worn  at  night  for  a  prolonged  period  after  re- 
covery is  well  advanced.  This  extends  into  many  weeks  or  months, 
and  it  is  very  important  to  keep  the  patient  under  observation  dur- 
ing this  period  of  splint  removal,  as  contractures  may  occur  long 
after  recovery  of  muscle  power  and  tone  is  apparently  complete. 

Corrective  Splinting. — In  an  old  deformity  resulting  from 
paralysis  of  nerve  there  are  three  tissues  entering  into  the  con- 
tracture, ligament,  tendon,  and  muscle.  Ligaments  are  nonelastic; 
muscle  possesses  elasticity.  Care  must  be  taken  that  nonelastic  tis- 
sue is  not  unnecessarily  torn  by  efforts  at  forcible  correction.     On 


ABSTRACTS   OF   WAR  SURGERY  395 

account  of  nutritional  changes,  affected  structures  atrophy  and 
become  less  resistant  to  trauma.  There  is  danger  of  rupture  of  liga- 
ments and  even  avulsion  of  bone  at  the  point  of  ligamentous  at- 
tachment. For  this  reason,  nonoperative  correction  of  deformity- 
is  always  preferable  in  cases  where  it  can  be  accomplished  by  this 
method.  It  is  a  slow  and  often  tedious  process,  but  eliminates  the 
danger  of  injury  to  atrophic  muscles,  ligament,  and  bone,  which 
may  occur  from  rough  handling  under  ether.  Many  patients  have 
been  through  several  operations  and  would  themselves  prefer  a 
slower  convalescence  to  further  operative  interference. 

If  proper  patience  is  exercised,  successful  correction  of  very  ex- 
tensive deformity  may  be  accomplished  by  gradual  stretching  of 
contractures  with  splints.  The  initial  selection  and  fitting  of  the 
splint  is  of  great  importance,  and  accepted  principles  of  splint  ap- 
plication must  be  kept  constantly  in  mind.  Corrective  pressure  is 
borne  on  soft  tissues,  and  the  amount  that  can  be  applied  is  limited. 
Constant  watchfulness  is  required  to  avoid  skin  or  tissue  necrosis. 
The  splint  should  be  removed  at  frequent  intervals  and  regular 
physical  treatment  given  both  for  the  purpose  of  forestalling  pres- 
sure injury  and  to  increase  pliability  and  local  circulation.  Skin 
sensation  may  be  absent  or  lessened,  and  many  patients  are  quite 
uncomplaining.  The  vigilance  of  the  attending  surgeon  should  be 
constant  to  assure  as  rapid  correction  as  the  skin  resistance  will 
permit.  Adjustments  left  to  the  control  of  the  patient  are  unwise, 
and  the  judgment  of  nurses  and  orderlies  must  not  be  trusted  too 
implicitly.  It  is  of  great  importance  to  gain  the  cooperation  of  the 
patient  himself  by  explaining  the  purpose  of  the  splint  and  the 
necessity  for  continuous  treatment,  otherwise  he  may  loosen  splints 
at  night  and  retard  his  own  recovery. 

Physiotherapy. — Pathology  of  Nerve  Repair. — A  severed  nerve 
begins  active  efforts  of  repair  immediately  in  a  clean  wound;  as 
soon  as  infection  is  checked  in  a  septic  wound.  The  nerve  ten- 
drils grow  in  loose  granulation  tissue  and  are  very  delicate  and 
easily  injured.  During  this  stage  vigorous  treatment  of  the  in- 
jured part  does  only  harm  to  the  new  forming  tissues. 

Gentleness  is  the  first  caution  in  beginning  routine  treatment 
necessary  during  repair  of  injured  nerves. 

Position  to  prevent  tearing  of  the  delicate  tendrils  must  be 
maintained  constantly.  For  two  or  three  weeks  after  injury  or 
operation  the  splint  should  not  be  removed  for  treatments. 

As  soon  as  opportunity  has  been  allowed  for  the  wound  to 
solidify,  further  treatment  should  begin.     The  splint  must  be 


896  ABSTRACTS  OF  WAR  SURGERY 

removed  every  day  or  several  times  a  day  and  proper  physical 
treatment  started. 

Treatment. — The  order  of  application  of  the  usual  remedial 
measures  will  vary  with  the  individual  case.  In  general,  hydro- 
therapy presents  an  early  method  of  great  value.  Hot  packs  are 
useful  as  a  preliminary  to  massage.  Contrast  baths  with  varia- 
tions from  50  to  120  degrees  of  temperature  are  of  service  in  in- 
creasing nutritional  repair.  The  whirling  and  bubbling  baths  and 
hose  baths  under  heavy  pressure  are  valuable. 

Electrotherapy. — Electricity  in  addition  to  its  diagnostic  value 
is  of  pronounced  assistance  as  a  mechanical  means  of  stimulation 
to  muscle.  The  latest  type  of  coil,  known  as  the  Bristow  coil, 
has  become  the  recognized  method  for  the  application  of  faradism 
on  account  of  its  simplicity  and  the  fact  that  its  construction  al- 
lows of  its  use  without  discomfort  to  the  patient.  It  may  not  be 
out  of  place  to  explain  the  purpose  of  electricity.  Too  often  the 
lay  impression  that  electricity  possesses  some  miraculous  force 
which  it  can  transmit  to  nerves  prevails  among  our  profession. 
The  action  of  electricity  in  the  recovery  after  nerve  injury  is 
upon  the  muscles  alone  and  not  the  nerves.  Its  first  effect  on 
muscle  tissue  is  to  maintain  tone  and  aid  nutrition  by  direct  stim- 
ulation of  muscle  fiber.  Secondly,  it  produces  contraction  of 
muscle  in  the  early  stages  of  reinnervation  during  convalescence 
and  thus  exercises  the  feebly  contracting  muscles  and  hastens 
the  return  of  power. 

Thermotherapy. — Heat  may  be  applied  by  means  of  hot  baths 
or  baking  chambers.  "While  kerosene  or  gas  may  be  used,  an  elec- 
tric cabinet  will  prove  more  convenient  and  is  usually  available. 
Extraordinary  temperatures  may  be  borne  by  the  perspiring  skin 
and  nutritional  improvement  follows  their  use.  Both  hydro-  and 
thermotherapy  are  most  useful  as  preliminaries  to  massage. 

Massage. — This  is  the  most  useful  and  generally  applicable 
method  of  physical  treatment  in  these  cases.  Many  inventions 
have  sought  to  supersede  the  human  hand  as  instruments  of  mas- 
sage but  without  success.  Attention  should  first  be  paid  to  main- 
taining the  nutrition  of  paralyzed  muscles.  The  overlying  skin, 
often  atrophic,  benefits  equally  from  the  treatment.  As  ex- 
plained in  discussing  the  pathology  of  nerve  repair  great  gentle- 
ness should  guide  the  masseur  during  the  early  stages  of  work 
with  recent  injuries.  Effleurage  and  wholly  passive  treatment 
with  the  part  retained  by  a  proper  splint  is  followed  gradually 
by  more  vigorous  methods  during  temporary  removal  of  the 
splint.    Work  should  be  done  with  the  paralyzed  muscle  relaxed 


ABSTRACTS  OF  WAR  SURGERY  397 

and  the  deformity  overcorrected  and  the  patient's  position  while 
being  massaged  must  be  wisely  planned.  For  example,  in  wrist- 
drop have  the  hand  in  supination  and  the  reverse  in  paralysis 
of  the  median  and  ulnar  nerves.  In  circumflex  involvement,  the 
patient  should  be  lying  on  his  back  and  the  arm  raised  beyond  a 
right  angle  in  abduction.  Likewise  in  foot-drop  a  prone  position 
with  foot  hanging  over  the  edge  of  the  table  will  lessen  the  tend- 
ency toward  plantar  flexion,  or  the  patient  may  be  made  to  sup- 
port the  foot  at  right  angles  by  holding  the  ends  of  a  bandage 
looped  about  the  toes. 

The  selection  of  efficient  operators  is  a  matter  for  careful  con- 
sideration. Not  only  should  we  insist  on  well  trained  and  experi- 
enced masseuses  but  they  should  not  be  expected  to  undertake 
too  many  cases  in  a  day.  It  has  been  found  in  English  hospitals 
that  one  operator  can  care  for  about  15  cases.  If  more  than  20 
cases  are  assigned  to  one  masseuse  the  quality  of  her  work  de- 
teriorates noticeably. 

Corrective  exercises  should  follow  the  gentler  forms  of  mas- 
sage necessary  in  freshly  wounded  cases,  and  are  begun  at  once 
in  older  cases  with  deformity  already  developed.  Force  should 
be  wisely  graded,  as  it  is  in  this  type  of  work  that  much  damage 
may  be  done  through  the  use  of  too  vigorous  methods.  Resistive 
and  assistive  exercises  are  of  great  benefit  in  the  development 
of  muscular  strength  and  the  reeducation  of  the  patient  in  the 
use  and  control  of  muscle. 

Finally  it  is  the  duty  of  the  masseuse  to  follow  up  the  patient 
even  after  he  has  recovered  sufficiently  to  begin  active  exercise 
and  training  in  the  curative  workshop.  Supplementary  massage 
and  direction  is  often  of  great  assistance  at  this  time  in  hasten- 
ing the  wounded  man  along  the  road  toward  the  complete  restora- 
tion of  voluntary  function. 


JAWS  AND  FACE 

EARLY  CARE  OP  GUNSHOT  WOUNDS  OF  THE  JAWS  AND 
SURROUNDING  SOFT  PARTS.  (Submitted  by  Subsec- 
tion of  Plastic  and  Oral  Surgery  of  the  Surgeon  General's 
office  as  a  basis  for  lectures  to  be  given  in  Medical  Officers' 
Training  Camps.) 

Of  not  uncommon  occurrence  in  the  present  war  are  those 
distressing  wounds  of  the  face  and  jaw  bones  which  have  at- 
tracted particular  attention  not  only  on  account  of  the  disfigure- 
ment which  they  cause,  but  even  more  so  from  the  difficulty  that 
was  at  first  encountered  in  dealing  with  them.  This  difficulty  is 
the  logical  outcome  of  an  attitude  that  regarded  dentistry  and 
surgery  as  two  distinct  and  separate  professions.  As  long  as  this 
theory  was  allowed  to  dominate  practice,  a  man  who  had  an  exten- 
sive injury  of  the  face  and  jaw  bones  had  about  as  much  chance  for 
an  ideal  result  as  had  the  man  with  an  open  fracture  of  a  limb  in 
the  days  when  the  physician  and  the  bone  setter  could  find  no 
common  ground  upon  which  to  meet.  The  bone  setter  and  the 
physician  who  refused  to  recognize  the  surgeon,  are  of  the  past, 
but  the  surgeon  and  the  dentist  in  their  relation  of  each  other 
only  too  frequently  perpetuate  the  agnosticism  of  those  older  prac- 
titioners. 

It  is  now  accepted  as  axiomatic  that  in  dealing  with  an  open  frac- 
ture of  the  thigh,  the  fixation  of  the  bones  and  the  treatment  of 
exposed  tissues  should  be  concurrent,  and  that  early  treatment  is 
one  of  the  most  important  factors.  It  is  not  universally  recognized 
that  these  same  principles  hold  in  the  treatment  of  a  wound  in- 
volving the  jaw  bone  and  the  soft  tissues,  whether  it  be  the  result 
of  an  industrial  accident,  a  removal  of  a  tumor,  or  a  war  injury. 

The  surgeon  has  expended  much  study  upon  making  himself 
master  of  the  various  means  of  splinting  the  injured  limb,  but 
proper  fixation  of  a  fractured  jaw  can  only  be  done  by  the  use  of 
dental  splints.  These  he  can  not  apply  himself,  and  he  has  not  al- 
ways sought  the  help  that  the  dentist  could  so  easily  lend. 

The  late  von  Langenbeck,  after  the  war  of  '70-71,  said,  "I  would 
not  care  to  go  through  another  campaign  without  the  help  of  skilled 
technicians  to  aid  in  the  care  of  these  jaw  injuries." 

398 


ABSTRACTS  OF  WAR  SURGERY  399 

The  surgeon  is  not  technically  trained  to  splint  these  cases,  yet 
early  proper  fixation  is  one  of  the  most  important  points  of  the  treat- 
ment. The  dentist  as  such  is  not  trained  to  care  for  the  wounded 
tissues  beyond  fixation  of  the  bones,  yet  repair  of  the  soft  tissues 
and  proper  drainage  may  be  equally  important.  A  few  have 
bridged  this  "no  man's  land"  between  surgery  and  dentistry,  re- 
cently a  much  larger  number  have  learned  cooperation,  but  today 
I  believe  that  the  majority  are  pursuing  their  separate  ways,  that 
a  patient  with  a  jaw  injury  will  be  treated  either  by  a  surgeon 
or  a  dentist,  neither  of  whom  is  master  of  all  of  the  problems,  and 
that  either  the  fixation  or  the  care  of  the  tissues  will  suffer  ac- 
cordingly. Of  the  two,  the  dentist  is  the  one  more  likely  to  recog- 
nize his  need  of  help. 

It  is  or  has  been  the  custom  to  transport  these  cases  back  to 
special  centers  where  qualified  men  are  stationed.  In  the  meantime 
the  patients  receive  what  might,  for  want  of  a  better  term,  be  called 
general  treatment.  We  have  recently  been  told  by  Crile  that  the 
most  important  step  in  the  preparation  for  the  care  of  our  wounded 
is  to  plan  to  give  them  the  proper  operative  treatment  within  the 
first  twelve  hours,  and  if  this  is  done,  that  primary  union  may  be 
obtained  in  90  per  cent  and  that  gas  gangrene,  etc.,  may  by  this 
means  be  eliminated.  This  may  be  too  much  to  expect  literally  of 
mouth  injuries,  but  I  feel  absolutely  certain  that  in  over  90  per 
cent  of  these  cases  earlier  treatment  would  accomplish  even  better 
results  than  late  treatment  where  reconstruction  must  overshadow 
conservation,  and  that  Kazan jian,  Morestin,  and  the  others,  could 
accomplish  even  better  results  in  the  individual  cases  with  less 
effort  and  less  distress  to  the  patient,  if  they  could  have  their  plan 
of  treatment  started  in  the  earlier  hours  after  the  injury,  than  later 
when  the  wound  is  complicated  by  infection  muscular  spasm,  infil- 
tration of  the  tissue  or  scar  contraction. 

In  the  light  of  our  past  clinical  observation  and  of  what  we 
have  learned  from  workers  abroad  it  is  our  hope  to  place  in  every 
evacuation,  base  and  recovery  hospital,  men  who  are  familiar  with 
the  problems  and  technic  of  dealing  with  these  face  and  jaw  in- 
juries so  that  from  the  very  first  each  of  these  patients  will  re- 
ceive the  best  that  surgery  has  to  offer. 

Early  Wounds. — Under  this  heading  would  be  included  wounds 
of  twelve  hours  or  less,  but  about  the  face  where  the  blood  sup- 
ply is  excellent,  wounds  of  twenty-four  hours'  duration  or  even 
longer  might  under  certain  circumstances  fall  into  this  class. 


400  ABSTRACTS  OF  WAR  SURGERY 

Three  objects  are  to  be  attained  in  the  treatment  of  any  wound : 
(1)  control  of  hemorrhage,  (2)  control  of  infection  and  (3)  ana- 
tomic restoration.  The  means  of  accomplishment  of  each  one  of 
these  is  closely  allied  to  that  used  to  attain  either  of  the  other 
two. 

Control  of  Hemorrhage. — The  simplest  procedure  is  the  sutur- 
ing of  the  separated  tissues,  larger  bleeders  when  seen  may  be 
caught  and  tied,  while  bleeding  from  depth  may  require  packing 
or  ligation  of  an  artery  in  continuity. 

Ligation  of  a  lingual  artery,  when  indicated,  is  as  a  rule  a  very 
satisfactory  operation,  because  it  is  almost  terminal  in  its  distri- 
bution. Ligation  of  the  trunk  of  the  external  carotid  is  very  much 
less  satisfactory  except  for  wounds  of  its  primary  divisions,  be- 
cause the  anastomoses  are  so  free  that  the  bleeding  may  scarcely  be 
influenced. 

A  serious  objection  to  ligation  of  the  external  carotid  is  that 
of  sepsis  and  secondary  hemorrhage  occurring  at  the  site  of  the 
ligation,  necessitating  ligation  of  the  common  carotid.  A  good  rule 
is  to  ligate  all  branches  of  the  external  carotid  as  far  as  possible 
from  the  parent  trunk,  and  not  to  tie  the  ligature  sufficiently  tight 
to  crush  the  wall  of  the  vessel.  Approximation  of  the  intima  is  all 
that  is  needed. 

The  common  carotid  should  be  tied  only  when  absolutely  neces- 
sary.   The  risk  to  life  and  brain  function  is  very  great. 

Hemorrhage  from  the  posterior  part  of  the  tongue  may  require 
ligation  of  a  lingual  artery;  bleeding  from  further  forward  is 
usually  controlled  by  one  or  two  deep  sutures,  possibly  tied  over 
a  piece  of  gauze.  Hemorrhage  from  the  pharynx  may  strongly 
suggest  the  ligation  of  an  external  carotid  but  it  is  important 
to  determine  which  one  is  involved.  By  alternate  compression 
of  the  common  vessel  against  the  carotid  tubercle  on  each  side 
with  careful  sponging,  a  valuable  hint  may  be  given  as  to  which 
is  to  be  attacked. 

Bleeding  from  the  cavities  of  the  face,  natural  or  artificial, 
is  as  a  rule  best  treated  by  packing  with  mildly  antiseptic 
gauze.  Iodoform  with  balsam  of  Peru  or  even  other  noncorrosive 
antiseptics  may  be  used,  but  these  packs  should  not  remain  in 
place,  without  being  changed  for  more  than  24  hours  and  should 
in  almost  every  instance  be  put  in  from  the  mucous  surface.  Even 
the  pharynx  may  be  packed  tightly  after  a  tracheotomy.  In  the 
neck  and  submaxillary  region,  the  wound  should  be  enlarged  and 
the  bleeding  point  ligated. 


ABSTRACTS  OF  WAR  SURGERY  401 

Prevention  of  Sepsis. — This  is  to  be  accomplished  by  (a)  the 
removal  of  foreign  bodies  and  damaged  tissue,  (b)  control  of 
hemorrhage,  (c)  early  accurate  approximation  of  the  tissues 
without  undue  tension,  (d)  rest  of  the  parts,  (e)  drainage  of  all 
actual  or  potential  pockets. 

In  the  bony  part  of  the  face,  bone  fragments  or  projectiles 
may  be  lodged  and  require  special  procedures  for  their  detec- 
tion, but  if  seen  early,  careful  palpation  will  reveal  even  very 
small  bodies  lodged  in  the  pharyngeal  wall,  the  tongue,  cheeks,  or 
floor  of  the  mouth.  In  a  patient  with  a  muscular  neck  external 
palpation  is  much  less  satisfactory. 

All  absolutely  dead  soft  tissue  should  be  removed  and  when 
not  too  extensive  it  is  better  to  cleanly  excise  all  badly  contused 
tissue  that  borders  wounds.  All  absolutely  free  bone  spicules 
should  be  removed,  but  no  fragment  that  has  any  attachment 
should  be  disturbed. 

Control  of  hemorrhage  has  already  been  considered.  Approxi- 
mation of  the  tissues  and  drainage  will  be  taken  up  later. 

Rest  of  the  bones  will  be  considered  under  splinting.  Physio- 
logic rest  is  as  important  as  in  any  case  of  injury.  Nothing  will 
interfere  with  the  rest  more  than  lack  of  proper  breathing  space. 

Immediate  Fixation  of  Fractures. — Partly  from  want  of  early 
treatment,  cases  of  gunshot  fracture  of  the  jaws  are  often  received 
in  base  hospitals  with  marked  deformity,  the  wounds  septic  and 
inflamed.  If  the  injury  is  in  the  region  of  the  symphysis,  with 
part  of  the  chin  carried  away,  the  two  halves  of  the  mandible  are 
apt  to  fall  together  toward  the  median  line,  narrowing  the  arch. 
In  lateral  fractures,  the  larger  fragment  is  drawn  over  toward 
the  affected  side.  The  longer  these  displacements  are  allowed  to  con- 
tinue, the  greater  the  difficulty  experienced  in  reduction.  In  the 
treatment  of  gunshot  fractures  of  the  jaws  and  associated  wounds 
of  the  soft  parts,  practically  all  workers  in  the  war  zone  are  agreed 
that  the  chief  aim  should  be  the  reestablishment  as  soon  as  possible 
of  the  normal  occlusion  of  the  remaining  teeth  of  the  two  jaws 
together  with  early  closure  or  approximation  of  the  soft  parts  with 
provision  for  adequate  drainage.  The  principle  should  be  in- 
augurated at  the  front  where  the  treatment  given  should  be  part 
of  a  general  plan  to  be  followed  throughout.  Several  methods  of 
temporary  fixation  of  the  fracture  are  available,  according  to  the 
needs  of  individual  cases,  as  follows: 

(a)  If  the  upper  jaw  is  intact,  a  roll  of  softened  dental  model- 
ing composition  is  placed  between  the  teeth,  and  the  upper  and 


402  ABSTRACTS  OF  WAR  SURGERY 

lower  teeth  brought  into  as  nearly  correct  occlusion  as  possible, 
the  composition  being  then  allowed  to  harden  in  position.  Addi- 
tional stability  is  afforded  by  a  chin  cup  of  modeling  composition, 
held  in  place  by  an  elastic  head  band.  This  method  has  the  dis- 
advantage that  no  breathing  space  is  afforded  between  the  teeth, 
and  no  provision  is  made  for  accommodation  of  swelling  of  soft 
parts  within  the  mouth. 

(b)  A  stock  splint  of  suitable  size  made  on  the  Gunning  idea, 
of  aluminum,  may  be  used  to  hold  the  parts  temporarily  in  approxi- 
mate position.  It  is  applied  by  filling  an  upper  and  lower  groove 
that  receives  each  dental  arch  with  softened  modeling  composition 
and  forcing  the  teeth  deep  into  the  composition  with  the  fragments 
of  the  fractured  arch  in  relatively  good  position.  The  chin  is  then 
supported  by  a  chin  cup  and  elastic  head  bandage.  A  splint  of  this 
type  fixes  the  mouth  with  the  jaws  partly  open,  thus  providing 
breathing  and  feeding  space,  and  room  for  the  tongue  to  swell. 

(c)  Pickerill's  modification  of  the  Kingsley  splint  has  the  ad- 
vantage that  the  mouth  may  be  opened.  It  consists  of  a  tray  of 
light  metal,  with  arms  made  of  stout  wire  soldered  to  the  body, 
and  made  in  several  sizes.  The  splint  is  first  tried  in  the  mouth 
over  the  teeth,  and  if  too  deep  at  any  point  is  trimmed  with  scissors 
and  otherwise  adapted  with  pliers.  Modeling  composition  softened 
in  hot  water  is  placed  in  the  splint  and  the  latter  is  then  pressed 
down  into  position  over  the  teeth  and  the  jaw,  care  being  taken  that 
the  fragments  are  in  normal  position.  A  bandage  is  passed  under 
the  mandible  up  between  each  arm  of  the  splint  and  the  cheek, 
over  the  arm  and  down  under  the  mandible,  where  it  is  tied 
firmly. 

(d)  Intermaxillary  fixation  by  direct  application  of  wire  liga- 
tures to  the  teeth  of  the  upper  and  lower  jaws  is  often  of  value 
either  as  a  temporary  or  a  permanent  measure.  For  this  purpose 
flexible  iron  or  brass  wire,  24  or  26  gauge,  may  be  used.  The  wire, 
cut  into  a  13-inch  length,  is  bent  in  the  middle,  and  by  means  of 
forceps  is  passed  from  the  lingual  surface  through  the  interdental 
space  on  each  side  of  the  tooth  to  be  ligated.  An  assistant  holds 
the  loop  of  the  wire  well  down  on  the  lingual  side  of  the  neck  of 
the  tooth,  while  the  operator,  having  obtained  a  firm  grasp  on 
each  end,  makes  a  twist  of  two  full  turns.  This  is  the  most  im- 
portant part  of  the  application  of  the  wire  ligature.  It  should 
grasp  the  neck  of  the  tooth  so  firmly  as  to  preclude  any  motion. 
The  ligature  can  be  tightened  with  hemostatic  forceps,  but  it  is 
better  to  get  the  tension  while  the  first  twist  is  being  made.      The 


ABSTRACTS  OF  WAR  SURGERY  403 

serrations  on  the  jaws  of  the  forceps  weaken  the  wire  wherever  they 
grasp  it.  If  possible,  ligatures  are  applied  to  two  adjacent  teeth 
on  either  side  of  the  fracture  and  to  two  corresponding  teeth 
of  the  upper  jaw.  The  upper  wires  are  then  twisted  with  the 
lower,  the  wire  around  the  more  posterior  of  the  two  lower  teeth 
being  twisted  with  the  wire  around  the  more  anterior  of  the  teeth 
above  and  vice  versa  so  that  the  wires  are  crossed.  While  the 
upper  wires  are  being  twisted  with  the  lower,  the  teeth  should  be 
held  in  occlusion  by  pressure  from  below  the  chin.  It  is  extremely 
important  that  the  teeth  be  held  in  proper  occlusion  while  the 
wires  are  being  tightened.  Wire  ligatures  put  on  by  this  method 
will  not  slip  or  become  untwisted,  but  the  incisor  teeth  offer  poor 
anchorage,  and,  owing  to  the  slight  constriction  at  its  neck,  the  ca- 
nine is  a  difficult  tooth  to  wire.  In  fractures  of  the  upper  jaw,  to 
prevent  displacement,  the  metal  Gunning  splint  may  be  applied 
with  a  bandage  under  the  chin.  Where  there  has  been  extensive 
comminution  of  the  bones  of  the  nose  and  upper  jaw  regions,  the 
bandage  should  not  make  pressure  over  these  parts. 

Closure  of  Soft  Parts  and  Drainage. — Wounds  of  the  soft  parts, 
if  seen  early  before  infection  has  occurred  may  frequently  be  im- 
mediately repaired  by  suture.  The  wound  is  cleansed  of  all  blood 
clots,  hemorrhage  is  controlled  and  foreign  bodies  are  removed; 
with  the  latter  are  included  totally  detached  bone  fragments. 
Above  the  lower  border  of  the  body  of  the  mandible,  local  and  gen- 
eral conditions  permitting,  immediate  closure  of  the  wound  should 
be  made,  but  all  shredded  and  pulpefied  tissue  is  removed  by  clean 
excision,  no  attached  fragments  of  bone  being  removed.  If  the 
defect  is  too  large  for  simple  suture,  then,  local  and  general  con- 
ditions permitting,  undermining  of  the  borders  may  be  done  with 
provision  for  drainage  of  these  pockets,  or  the  wound  is  closed  by 
flap  operation.  If  the  parotid  duct  is  severed,  provision  for  drain- 
age into  the  mouth  is  made.  In  the  neck  there  are  two  especially 
notable  danger  zones  in  reference  to  subsequent  infection:  (1) 
The  lower  parts  of  the  subfascial  spaces  that  lead  directly  into  the 
mediastina  and  (2)  the  immediate  wound  area  about  the  ligated 
carotid  or  carotid  primary  branches.  In  the  first  instance  the  dan- 
ger is  that  of  mediastinitis,  whereas  in  the  second  it  is  the  possi- 
bility of  secondary  fatal  hemorrhage.  The  blood  supply,  and  there- 
fore the  resistance  to  sepsis,  is  not  as  good  in  the  neck  as  on  the 
face.  Recent  wounds,  after  proper  preparation,  are  sutured  with 
ample  provision  for  drainage.     If  the  deep  subfascial  spaces  are 


404  ABSTRACTS  OF  WAR  SURGERY 

opened,  in  the  deepest  part  of  the  lower  end  of  each  invaded 
space  a  small  strip  of  gauze  packing  is  placed.  If  one  of  the 
primary  branches  of  the  external  carotid  artery  is  divided,  this 
part  of  the  wound  is  packed,  because  sepsis  here  predisposes  to 
fatal  secondary  hemorrhage.  A  wound  in  the  trachea  or  larnyx 
may  be  sutured,  the  more  superficial  part  being  packed  to  furnish 
drainage  away  from  the  tracheal  lumen.  A  wound  of  the  pharynx 
or  esophagus  is  sutured  and  the  line  of  union  reinforced  by  some 
superimposed  tissue,  but  the  mediastinum  is  guarded  by  a  light 
packing  at  the  lowest  part  of  the  wound.  These  packs  are  not  al- 
lowed to  remain  when  fouled.  A  complete  wound  through  the 
floor  of  the  mouth,  as  Billroth  long  ago  pointed  out,  should  never 
be  primarily  sutured  on  account  of  the  danger  of  indurating  in- 
fection and  secondary  hemorrhage.  If  the  bones  are  involved  then 
the  remaining  portions  should  be  splintered  in  their  proper  posi- 
tions and  no  attached  fragment  removed.  Every  pocket,  every 
open  bone  cavity  including  the  maxillary  sinus,  and  the  lower  end 
of  every  fracture  line  should  have  efficient  dependent  drainage. 
If  this  is  done  early,  it  is  surprising  to  note  the  conservation  and 
regeneration  that  may  result.  After  the  bony  fixation  and  drain- 
age have  been  provided  for,  then  the  soft  parts  may  be  repaired  as 
outlined  above.  The  necessity  for  late  repairs  will  largely  be  in  in- 
verse ratio  to  the  early  care  that  the  case  has  received. 

The  swelling  of  the  tongue  and  other  soft  tissues  as  well  as 
nasal  obstruction  often  renders  breathing  difficult  in  cases  of 
gunshot  injury  of  the  face  and  jaws.  Owing  to  the  high  mortal- 
ity following  it,  tracheotomy  should  be  avoided  if  it  be  possible 
to  ensure  a  sufficient  amount  of  air  by  any  other  means.  Draw- 
ing the  tongue  forward  and  maintaining  it  in  this  position  by  a 
thread  attached  to  the  chin  with  adhesive  plaster,  or  the  inser- 
tion of  rubber  tubing  through  the  mouth  and  passed  well  back 
into  the  pharynx  will  in  many  cases  allow  of  adequate  respiration. 
'  Control  of  Sepsis. — Early  localized  sepsis  in  a  wound  may  at 
times  be  controlled  by  excision  of  the  walls.  This  refers  particu- 
larly to  gas  bacillus  infection. 

Diffuse  indurations  are  best  treated  by  hot  packs  or  ice,  with 
incision  of  softened  areas,  the  wound  itself  being  treated  by 
accepted  antiseptic  methods.  As  a  rule,  little  is  accomplished  by 
early  incisions  in  rapidly  extending  indurations  except  the  type 
known  as  Ludwig's  angina.  (See  Blair's  "Surgery  and  Diseases 
of  the  Mouth  and  Jaws,"  3rd  ed.) 

Every  softened  or  brawny  area  should  be  incised  and  given  de- 


ABSTRACTS  OF  WAR  SURGERY  405 

pendent  drainage.  If  cavities  are  opened  within  the  mouth, 
especially  where  they  lie  close  to  the  bones,  careful  repeated  pack- 
ing of  these  cavities  should  usually  be  practiced.  Careful  atten- 
tion to  this  will  do  away  with  the  odors  that  frequently  render 
these  cases  so  objectionable.  Frequent  irrigation  of  these  cavities 
with  peroxide  of  hydrogen  is  not  as  satisfactory  as  repeated 
packing  where  it  can  be  practiced. 

Secondary  Hemorrhage. — Secondary  hemorrhage  is  the  result 
of  sepsis,  by  which  the  temporarily  occluded  artery  is  again 
opened.  This  usually  occurs  six  to  eighteen  days  after  the  in- 
jury. The  first  consideration  is  the  control  of  the  bleeding,  but 
the  presence  of  the  sepsis  should  not  be  forgotten.  Measures  that 
stop  the  hemorrhage  but  further  the  sepsis  are  as  a  rule  to  be 
condemned.  Where  it  can  be  practiced,  the  wound  should  be 
cleaned  out  and  the  bleeding  controlled  by  simple  or  antiseptic 
packing  but  no  corrosive  antiseptic  should  be  used.  "Where  such 
is  packed,  the  packing  should  be  changed  sufficiently  often  to 
encourage  control  of  sepsis  regardless  of  the  recurrence  of  the 
bleeding.  Rest  of  the  parts  is  important.  For  many  cases  liga- 
tion of  the  contributing  artery  only  in  its  course  is  indicated. 

In  ligating  the  branches  of  the  external  carotid  this  could  be 
done  as  far  from  their  origin  as  possible,  and  great  care  should 
be  exercised  not  to  transfer  the  infection  to  the  site  of  ligation. 

Secondary  hemorrhage  from  the  external  carotid  itself  is  only 
to  be  controlled  by  ligation  of  the  common  carotid,  which  is  fol- 
lowed by  a  high  mortality  rate.  Our  observation  has  not  led  us 
to  believe  that  this  mortality  is  to  any  great  extent  lessened  by 
gradual  occlusion  of  the  common  carotid. 

Secondary  Repair  of  Defects. — The  operations  for  the  repair 
of  defects  that  have  not  been  closed  immediately  after  the  in- 
fliction of  the  wound,  may  be  undertaken  as  soon  as  sepsis  is  con- 
trolled, clean  healthy  granulations  have  been  established,  and  all 
dead  bone  thrown  off.  Before  closure  of  a  defect  is  undertaken,  all 
binding  scars  should  be  removed.  In  making  these  repairs  the 
neighboring  tissues  may  be  drawn  into  the  defect  to  a  certain  ex- 
tent, but  it  is  better  to  use  pedicled  flaps  from  neighboring  areas 
or  the  arm  than  to  simply  draw  the  tissues  together  over  large 
defects. 

Feeding  During  the  Treatment  of  a  Fracture  of  the  Jaw. — Food 
and  fresh  air  are  important  factors  in  the  treatment  of  any  frac- 
ture. With  a  fracture  of  the  jaw,  especially  if  the  jaws  are  wired 
together,  especial  attention  must  be  paid  to  the  feeding.  With  an 
interdental  splint,  ordinary  soft  foods  and  chopped  meat  can  be 


406  ABSTRACTS  OP  WAR  SURGERY 

taken  from  the  first.  When  the  jaws  are  wired  together,  the  diet 
must  often  be  restricted  entirely  to  fluids. 

Diet. — A  consideration  of  the  methods  of  administration  and 
the  character  and  variety  of  food  in  individual  cases  is  of  the  ut- 
most importance  when  a  patient  has  to  be  on  a  liquid  or  semisolid 
diet  for  weeks.  As  much  variety  as  possible  is  essential  in  order 
to  provide  sufficient  nourishment.  The  patient  on  liquid  diet  loses 
weight  at  first,  but  after  a  time  with  proper  selection  and  variation 
he  begins  to  regain  it.  Not  all  patients  thrive  on  a  purely  albumi- 
nous diet,  and  it  is  well  to  mix  it  with  liquid  potatoes,  gruels,  and 
fruit  juices.  Especially  in  older  people  highly  albuminous  diet  is 
apt  to  cause  diarrhea. 

The  method  of  administering  liquid  food  to  be  resorted  to  ac- 
cording to  the  exigencies  of  the  case  are: 

1.  Sucking  through  a  porcelain  goose-necked  feeder. 

2.  Funnel  with  tube  to  pharynx  through  mouth. 

3.  Tube  to  the  stomach. 

4.  Tube  through  the  nose. 

It  is  surprising  what  can  be  administered  through  a  half-inch 
tube  introduced  into  the  back  of  the  mouth,  even  in  the  way  of 
mashed  potatoes,  minced  meat,  etc. 

Semisolid  Dietary  for  Convalescent  Patients. — Same  as  above  in 
4  hourly  feeds. 

In  addition: 

Baked  custard 

Strained  fruit  juice  or  stewed  fruit 

Jelly 

Benger's  food 

Bread  and  milk 

Porridge 

(Per  diem) 
Convalescent  Semisolid. — 
Breakfast:     7:45  A.  M. 

Porridge,  1  pt.,  milk,  1  pt.,  sugar. 

Tea,  thin  bread  and  butter. 

Alternative,  bread  and  milk  or  gruel. 
Luncheon:     11:00  A.  M. 

Bread  and  milk,  or  beef  tea,  with  bread. 
Dinner:     1:00  P.  M.. 

Minced  meat,  mashed  potatoes,  greens. 

Milk  pudding. 
Tea:     4:00  P.  M. 

Tea,  or  bread  and  milk;   2  eggs  lightly  boiled,  poached,  fried  or 
scrambled. 

Bread  and  butter. 


ABSTRACTS  OF  WAR  SURGERY  407 

Supper:     7:00  P.  M. 

Cocoa,  1  pt.,  or  bread  and  milk. 

A  No.  18  French  gum  catheter  introduced  low  in  the  esophagus 
through  the  nostril  and  anchored  to  the  lip  with  adhesive  plaster 
is  usually  well  tolerated  for  weeks,  and  through  this,  liquids  may  be 
given  through  a  funnel  or  semisolids  may  be  forced  from  a  syringe. 
If  the  catheter  is  placed  too  deep  in  the  esophagus,  fluids  may  re- 
gurgitate through  the  tube  and  a  slip  on  the  tube  may  be  necessary. 
If  the  tube  is  not  sufficiently  far  down,  food  may  regurgitate 
around  the  catheter. 

For  convenience,  the  following  summary  of  dietary,  taken  from 
Kazanjian,  comprising  the  range  of  liquids,  serniliquids,  and  semi- 
solid diet,  is  given  here. 

Summary  of  Dietary  in  Acute  Injury  of  Jaw. — 

Liquid  through  esophageal  tube  or  mouth  tube. 

Every  2  hours  during  day. 

Every  4  hours  during  night. 
Milk  1  pt.,  egg  1,  or  strong  soup,  or  Benger's  food  with  egg;  or 
Bovril  made  with  milk,  or  thin  arrowroot. with  Valentine's  meat 
juice;   or  boiled  custard  with  addition  of  stimulants — brandy  or 
port  wine  as  ordered. 

Basis  of  dietary  24  hours: 

Milk,  4  pts.;  eggs,  4;  soup,  2  pints. 

Five  hundred  grams  of  perfectly  fresh  chopped  lean  beef  with 
an  equal  quantity  of  water,  soaked  for  six  hours  at  an  ice-cold 
temperature,  will  when  the  fluid  is  pressed  out,  yield  500  cubic 
centimeters  of  rich  beef  juice  which  may  be  taken  raw  or  put  into 
soups.  The  juice  expressed  from  boiled  or  baked  meats  is  much 
more  palatable,  but  not  so  economical.  Of  course,  no  dependence 
should  be  placed  upon  beef  tea  or  clear  soups. 

Definitive  Methods  of  Fixation  of  Jaw  Fractures. — Definitive 
immobilization  of  the  bones  can  usually  be  carried  out  within  a  few 
days  at  a  time  when  the  fractured  parts  can  still  be  moved  freely. 
The  former  occlusion  of  the  lower  teeth  with  the  upper  should  al- 
ways be  the  guide  in  fixation  of  the  fragments,  even  though  this 
entails  considerable  separation  between  the  fractured  ends. 

The  form  of  fixation  to  be  applied  depends  on  the  location  of  the 
fracture,  the  amount  of  substance  lost,  the  amount  of  displace- 
ment, the  number,  condition,  and  position  of  teeth  present.  Below 
is  given  a  rational  classification  of  gunshot  fractures  of  the  jaws, 
with  an  indication  of  the  form  of  apparatus  best  adapted  to  each 
type. 


408  ABSTRACTS  OF  WAR  SURGERY 

The  selection  and  adoption  of  the  best  method  of  fixation  for 
individual  cases  must  be  left  to  the  ingenuity  of  the  surgeon  and  his 
assistants.  In  a  general  way,  any  method  of  fixation  that  is  effec- 
tive and  allows  the  mouth  to  be  open,  is  better  than  one  in  which 
the  jaws  must  be  kept  closed.  The  latter  interferes  with  mastica- 
tion, predisposes  to  ankylosis,  and  hinders  drainage. 

A.  Recent  Fractures.' — 1.  Fracture  of  the  body  of  the  mandible 
anterior  to  the  last  existing  tooth  without  loss  of  substance. 

Fractures  of  this  type  frequently  occur  from  concussion,  where 
the  projectile  does  not  strike  the  jaw  itself,  or  if  so  has  largely 
spent  its  force.  They  may  be  treated  by  methods  of  fixation  em- 
ployed in  civil  practice,  among  the  best  of  which  are  the  vulcanite 
or  metal  jacket  splint  made  to  fit  over  several  teeth  on  each  side  of 
the  fracture,  i.  e.,  Gilmer's  lingual  band  splint  (see  Blair's  Sur- 
gery and  Diseases  of  the  Mouth  and  Jaws,  3rd  ed.,  p.  116)  may  also 
be  found  useful. 

2.  Fractures  of  the  body  of  the  mandible  anterior  to  the  last  ex- 
isting tooth,  with  few  teeth,  considerable  displacement,  or  loss  of 
substance. 

In  this  class  are  found  the  majority  of  gunshot  fractures.  "When 
there  is  loss  of  substance  at  the  symphysis,  the  fragments  tend  to 
be  drawn  together  in  front  with  the  occlusal  surfaces  of  the  teeth 
facing  inwards  toward  each  other.  In  the  lateral  portion  of  the 
bone,  the  loss  of  substance  causes  the  fragment  on  the  sound  side 
to  be  drawn  over  to  the  affected  side.  The  best  method  of  main- 
taining separation  and  fixing  the  fragments  in  their  normal  posi- 
tions in  relation  to  the  upper  teeth  in  these  cases  is  by  the  metal 
band  and  wire  splint,  either  made  in  one  solid  piece  or  applied 
in  sections  afterwards  fastened  together.  In  the  making  of  this 
splint,  several  teeth  on  each  fragment  are  fitted  with  ready  made 
thin  copper  bands  of  suitable  size,  trimmed  and  bent  so  as  to  leave 
the  occlusal  surfaces  free.  With  the  bands  in  place,  an  impression  is 
taken,  a  cast  made,  cut  at  the  line  of  fracture,  and  reassembled  with 
the  lower  teeth  occluding  properly  with  the  upper.  The  bands  of 
each  segment  are  then  soldered  to  form  one  piece,  and  the  two  sides 
united  by  soldering  a  heavy  wire  or  metal  band  which  passes  across 
the  seat  of  fracture.  The  piece  is  then  cemented  to  the  teeth  in  the 
mouth.  In  difficult  cases,  this  splint  may  be  made  in  two  sections 
applied  separately,  and  afterwards  fastened  together  with  liga- 
ture wire. 

In  cases  with  considerable  loss  of  substance,  where  there  is  a 


ABSTRACTS  OF  WAR  SURGERY  409 

tendency  for  the  lower  jaw  to  swing  over  to  one  side,  the  outer  sur- 
face of  the  splint  on  the  opposite  side  may  be  provided  with  a  metal- 
lic flange  to  engage  the  teeth  of  the  upper  jaw,  thus  acting  as  an 
inclined  plane  to  bring  the  teeth  into  proper  occlusion  when  the 
jaws  are  closed. 

3.  Fracture  of  the  mandible  behind  the  last  existing  tooth. 

The  form  of  apparatus  is  selected  to  best  suit  the  individual  case. 
These  cases  comprise  fractures  of  the  body  of  the  bone,  ramus,  or 
condyle,  with  or  without  loss  of  substance.  Where  there  is  no  ten- 
dency to  displacement  and  no  loss  of  substance,  the  simplest  form  of 
treatment  is  by  fixation  of  the  lower  jaw  to  the  upper  by  means  of 
ligature  wires  directly  applied  to  the  teeth  or  through  the  inter- 
vention of  bands  and  arches  around  the  teeth. 

In  fracture  of  the  angle  and  ramus  with  loss  of  substance,  if  the 
ramus  stays  in  good  position  this  form  of  wiring  may  be  sufficient, 
but  if  the  ramus  displaces  forward  or  laterally,  after  fixing  the  an- 
terior fragment  by  wiring  the  teeth  to  those  of  the  upper  jaw,  the 
ramus  may  be  steadied  in  position  by  drawing  it  back  with  a  hook 
passed  around  it  through  the  cheek,  or  a  lion- jaw  forceps  catching 
it  through  the  skin,  and  then  placing  modeling  composition  be- 
tween the  ramus  and  the  last  molars  above  and  extending  down 
behind  the  molars  below. 

Fractures  in  this  region  may  also  be  treated  through  the  medium 
of  upper  and  lower  swaged  metal  jackets  applied  separately  and 
then  fastened  together  by  means  of  ligature  wire  attached  to  the 
hooks  provided.  Occasionally  also,  in  cases  where  there  is  tendency 
for  displacement  of  the  jaw  to  one  side,  the  hooks  on  the  splint 
afford  attachment  for  intermaxillary  elastics,  this  force  being  used 
to  overcome  the  deviation. 

Where  it  is  desirable  to  dress  the  jaw  with  the  mouth  open, 
and  prevent  forward  displacement  of  the  ramus,  the  splint  de- 
scribed by  Herpin  is  applicable.  This  consists  of  metal  bridge 
with  a  vulcanite  extension  backward  which  embraces  the  anterior 
edge  of  the  ramus  of  the  jaw,  preventing  its  forward  displacement. 
If  necessary,  the  vulcanite  piece  may  be  made  removable,  and  can 
be  provided  with  a  jackscrew  extension  apparatus  so  that  the  ramus 
can  be  gradually  forced  backward  if  forward  dislocation  has  oc- 
curred. 

Gunshot  Fractures  of  the  Upper  Jaw. —  (a)  Partial  fractures  as 
a  rule  are  easily  maintained  in  position  by  some  form  of  appliances 
such  as  a  band  and  wire  splint,  or  a  swaged  metal  jacket  attached 


4.10  ABSTEACTS    OF   WAR   SURGERY 

to  the  upper  teeth.     In  unilateral  fractures  ligation  of  the  teeth 
of  the  sound  side  to  those  of  the  lower  jaw  is  often  efficient. 

(b)  In  transverse  fracture  of  the  entire  maxilla,  the  reversed 
Kingsley  bar  splint  combined  with  a  head  cap  as  described  by  Mar- 
shall (Blair,  p.  90)  is  suitable.  It  consists  of  a  swaged  metal  or 
vulcanite  piece  on  the  upper  teeth  with  heavy  iron  wire  bars  pro- 
jecting from  the  angles  of  the  mouth  to  provide  attachment  to  the 
head  cap.  The  head  cap  may  be  made  of  woven  material,  netting, 
metal  bands,  celluloid,  plaster  of  Paris,  etc. 

(c)  In  comminuted  fractures,  or  those  associated  with  much  loss 
of  bone,  the  modification  of  the  Kingsley  splint  is  not  applicable, 
for  the  upward  pull  of  the  bands  will  tend  to  displace  the  palate  and 
alveolar  parts  upward.  In  such  cases  a  swaged  metal  splint  is 
cemented  to  the  upper  teeth  and  attached  to  a  fixed  head  cap  by 
metal  rods  that  "will  hold  the  dental  arch  in  its  proper  relation  to 
the  lower  and  maintain  its  proper  distance  from  the  base  of  the 
skull. 

B.  Old  Fractures  of  the  Mandible  with  Partial  or  Nonunion,  and 
the  Fragments  in  Bad  Position. — 

By  carrying  out  the  principles  of  early  treatment  outlined  above, 
it  is  hoped  that  the  number  of  fractures  in  this  classification  will 
be  much  reduced.  For  these  cases,  two  general  methods  of  treat- 
ment are  available: 

1.  Operative  Treatment. — The  method  of  choice  in  these  cases 
is,  under  local  or  general  anesthesia,  to  divide  adhesions,  fibrous 
bands  or  callus  bringing  the  fragments  into  their  correct  re- 
lations, and  fixing  them  there  by  means  of  any  of  the  appliances 
described  in  the  previous  section  suitable  for  the  given  case  in 
hand.  Considerable  gaps  in  the  bone,  even  amounting  to  several 
centimeters  in  width,  produced  by  the  readjustment  of  the  frag- 
ments, may  be  in  time  solidly  filled  with  new  bone.  If  nonunion 
persists  after  several  months'  trial,  the  case  may  be  considered  suit- 
able for  replacement  of  the  lost  tissue  by  bone  or  cartilage  graft- 
ing. It  is  in  these  late  cases  especially  that  the  inclined  planes 
made  by  flanges  of  suitable  shape  to  engage  the  teeth  of  the  op- 
posite jaw,  are  of  especial  value  in  overcoming  the  tendency  to  re- 
turn of  the  fragments  to  their  old  incorrect  position.  In  operat- 
ing on  these  cases,  after  dividing  cicatrices,  the  separated  tissues 
may  be  kept  apart  by  means  of  softened  modeling  composition 
pressed  into  the  wound. 

2.  Orthopedic  Splints. — In  cases  of  displacement  of  lesser  degree, 


ABSTRACTS  OF  WAR  SURGERY  411 

or  where  for  some  reason  operative  measures  are  not  to  be  con- 
sidered, orthopedic  splints  for  the  gradual  restoration  of  the  frag- 
ments to  their  normal  position  may  be  employed.  Great  ingenuity 
is  manifested  in  the  adaption  of  these  principles  to  individual  cases. 
The  forms  of  apparatus  most  commonly  used  for  this  purpose  are : 
the  sectional  band  and  wire  splint,  the  jackscrew,  and  lugs  and  in- 
clined planes. 

Bandaging1. — Bandaging  in  connection  with  fractures  is  of  im- 
portance. The  most  useful  bandage  is  modification  of  the  Barton, 
which  avoids  the  disadvantage  of  the  latter  in  making  backward 
pressure  on  the  chin.  An  elastic  bandage,  preferably  a  piece  of 
rubber  dam  3  inches  wide,  if  not  put  on  too  tightly,  is  more  com- 
fortable and  more  effective  than  a  nonelastic  bandage. 

SURGICAL  AND  PROSTHETIC  TREATMENT  OF  FRAC- 
TURES OF  THE  JAWS  BY  WAR  PROJECTILES,  IN  AN 
EVACUATION  CENTER.— Frison,  Dufourmentel,  Bonnet- 
Roy,  and  Brunet.    Paris  Med.,  1917,  vii,  p.  202. 

The  privileged  situation  of  the  writers  in  a  very  important 
evacuation  center  in  the  immediate  neighborhood  of  the  front, 
giving  them  care  of  the  wounded  within  a  few  hours,  has  per- 
mitted them  to  gather  some  valuable  personal  experiences  on 
the  constant  and  intimate  collaboration  of  the  surgeon  and  the 
prosthetist. 

Immediate  Surgical  Treatment. — A  certain  number  of  simple 
fractures  by  shock,  falling  or  even  by  projectile,  has  been  ob- 
served, but  the  great  majority  of  mandibular  fractures  pre- 
sent themselves  with  the  usual  characters  of  war  fractures,  i.  e.,  they 
are  comminuted  and  infected. 

The  course  to  be  immediately  followed,  however,  will  differ 
in  the  two  cases.  If  it  is  universally  admitted  now  that  as 
perfect  toilet  and  aseptization  as  possible  of  a  region  of  frac- 
ture of  the  limbs  is  the  absolute  rule,  in  mandibular  fractures, 
according  to  their  experience,  this  can  be  followed  only  to  a 
limited  extent.  Infection  is  constant  and  inevitable,  since 
saliva,  food,  nasopharyngeal  secretion  maintain  it.  No  opera- 
tive measure  will  prevent  an  open  fracture  of  the  jaw  from 
being  infected  and  reinfected  incessantly.  On  the  other  hand, 
if  infection  is  constant,  it  is  never  grave,  so  to  speak,  and  puru- 
lent collections  which  can  occur  secondarily  in  the  neighbor- 
hood of  the  wounds  are  of  little  importance.     The  grave  infec- 


412  ABSTRACTS  OF  WAR  SURGERY 

tions  common  to  fractures  of  the  limbs  are  never  to  be  feared, 
and  gaseous  gangrene  in  particular  is  unknown  in  this  region. 
This  is  because  the  seats  of  fracture  are  drained  normally  both 
externally  and  by  the  mouth,  the  salivary  flow  sweeps  them  in- 
cessantly, moderating  the  infection  as  well  as  maintaining  it, 
and  there  is  no  doubt  that  these  peribuccal  regions  have  better 
defenses  than  the  majority  of  others. 

The  floor  of  the  mouth  itself,  considered  as  a  frequent  seat 
of  grave  phlegmons,  is  never  the  source  of  serious  menace.  The 
writers  have  only  observed  one  case  of  local  infection  with 
rapid  progress  and  disquieting  symptoms  in  a  wounded  man 
who  carried  a  shell  splinter  which  had  penetrated  by  the  mouth 
and  had  left  around  it  no  drainage  opening.  There  was  also  no 
mandibular  fracture.  A  submental  incision  quickly  cleared  up 
the  case.  However,  the  toilet  of  the  wound  should  be  made 
for  the  purpose  of  relieving  it  of  all  kinds  of  debris  (broken 
teeth,  fragments  deprived  of  periosteum,  shreds  of  soft  tissue), 
and  above  all  to  forestall  secondary  hemorrhage.  The  latter, 
in  fact,  results  most  often  from  the  presence  of  traumatizing 
splinters,  and  it  is  generally  the  lingual  artery  that  is  torn 
by  them  in  the  floor  of  the  mouth.  But  to  practice  this  toilet 
no  sort  of  anesthesia,  no  bistoury,  no  curette  is  needed.  The 
fingers  and  a  pair  of  forceps  nearly  always  suffice.  The  free 
splinters  are  lifted  out,  in  places  a  still  adherent  shred  of 
periosteum  is  detached,  to  be  left  in  the  wound;  sometimes  a 
cut  with  scissors  is  necessary  to  free  a  poorly  detached  shred ; 
sometimes  again  the  pointed  end  of  a  utilizable  fragment  is 
taken  off  with  a  rongeur.  All  this  is  only  slightly  painful, 
slightly  bloody,  and  rapid,  and  possesses  the  double  advantage 
of  avoiding  anesthesia,  which  augments  the  predisposition  of 
these  wounded  men  to  pulmonary  accidents,  and  incisions  more 
disfiguring  than  before.  Finally,  and  above  all,  if  the  remain- 
ing splinters  of  bone  should  be  cast  off  eventually,  they  do  not 
carry  with  them  their  periosteum,  which  will  constitute  valu- 
able centers  of  osteogenesis  in  the  loss  of  substance. 

The  enormous  serosanguineous  infiltration  of  the  floor  of  the 
mouth  which  is  frequently  observed,  disappears  of  its  own 
accord  in  a  few  days,  and  does  not  contraindicate  this  conserva- 
tive treatment. 

The  role  of  the  surgeon  is  not  limited  to  this.  He  must  also 
safeguard  respiration  and  alimentation.  For  the  first,  it  suf- 
fices to  assist  the  lack  of  support  of  the  tongue  by  application 


ABSTRACTS  OF  WAR  SURGERY  413 

of  a  traction  thread  attached  to  the  dressing.  If  the  patient  is 
not  put  to  sleep,  tracheotomy  is  always  avoided  when  the 
traumatism  is  anterior  to  the  pharynx.  For  feeding,  almost 
always  possible  spontaneously,  the  application  of  an  esophageal 
catheter  will  suffice  in  all  cases. 


WAR  INJURIES  OF  THE  JAW.— N.  G.  Bennett.    Practitioner, 
London,  1917,  xcix,  p.  201. 

Early  treatment  consists  in  control  of  hemorrhage,  support 
of  fractured  portions  of  the  mandible,  and  abatement  of  sepsis. 
Support  with  a  four-tailed  bandage  should  be  condemned,  as 
it  compresses  the  fragments  and  results  in  a  contracted  bone. 
For  the  sepsis,  almost  constant  irrigation  with  Wright's  saline 
solution,  or  nonirritant  antiseptics,  such  as  hydrogen  dioxide, 
boracic  acid,  hypochlorous  acid,  or  permanganate  of  potash,  is 
employed.  The  use  of  the  compressed  air  spray  and  local  ap- 
plication of  2  per  cent  tincture  of  iodine  is  advised. 

Extraction  of  Teeth  and  Roots. — As  soon  as  possible  all  loose 
teeth,  broken  teeth,  and  septic  roots  should  be  removed,  as  well 
as  the  teeth  in  the  immediate  vicinity  of  the  fracture.  There 
are  exceptions  to  this  rule,  and  judgment  is  required.  The  suc- 
cess of  subsequent  treatment  for  the  correction  of  displacement 
may  depend  very  much  upon  the  opportunity  of  fixing  splints 
to  the  teeth,  and  even  a  loose  or  broken  tooth  may  be  of  great 
value  temporarily  even  though  it  is  extracted  later.  As  regards 
the  teeth  adjacent  to  the  fracture,  removal  promotes  union,  but, 
on  the  other  hand,  their  presence  often  served,  for  the  time 
being,  to  prevent  dropping  together  of  the  fragments  into  false 
positions,  their  extraction,  therefore,  should  usually  be  deferred 
until  a  splint  has  been  fixed,  or  at  least  is  ready  for  fixing. 

The  objects  ultimately  to  be  attained  are : 

(a)  Firm  union  of  the  fractured  portions  of  bone. 

(b)  Restoration  of  the  jaws  as  nearly  as  possible  to  their  nor- 
mal form  and  function,  with  normal  occlusion  of  the  teeth. 

(c)  Replacement   of  lost  portions  by  prosthetic   appliance. 

(d)  Union  of  the  soft  tissues,  with  as  little  contraction  and 
scarring  as  possible,  by  immediate  suturing  or  gradual  healing 
by  granulation,  or  with  the  aid  of  subsequent  plastic  opera- 
tions. 

The  amount  of  bone  destroyed  determines  to  some  extent  the 
ultimate  result  to  be  attempted,  and  therefore  the  methods  to 
be  employed.     If  new   growth  of  bone   can  reasonably  be  ex- 


414  ABSTRACTS  OP  WAR  SURGERY 

pected  to  fill  the  gap,  correct  treatment  consists  in  reducing 
the  parts  to  their  normal  positions,  and  holding  them  there 
firmly  by  means  of  an  intraoral  or  other  splint.  If  this  can 
not  be  expected,  then  the  question  arises  whether  the  normal 
mandibular  contour  and  dental  occlusion  should  not  be  sacri- 
ficed to  some  extent,  in  order  to  approximate  the  fragments 
and  obtain  firm  bony  union  rather  than  an  unsatisfactory  fibrous 
union. 

"With  loss  of  bone  up  to  half  an  inch  in  length,  bony  union 
may  be  expected  with  some  confidence.  "With  a  loss  up  to 
three-quarters  of  an  inch,  or  even  more,  it  is  not  impossible 
under  favorable  conditions,  without  the  aid  of  a  bone  graft. 
Beyond  that  length,  replacement  by  natural  growth  can  not  be 
expected,  and  the  initial  course  of  treatment  is  to  some  extent 
determined  by  the  intention  to  make  use  of  a  bone  graft  ulti- 
mately. Larger  losses  involving  most  of  one  side  of  the  hori- 
zontal ramus  are  probably  beyond  the  aid  of  a  bone  graft. 

When  the  case  comes  under  treatment  reasonably  early,  two 
courses  present  themselves,  namely,  to  correct  the  displacement 
by  immediate  methods,  fixing  the  parts  firmly  by  means  of  a 
splint ;  or  to  employ  appliances  that  will  gradually  reduce  the 
displacement,  and  then  to  fix  as  before. 

Bennett's  experience  leads  him  to  believe  that  with  a  small 
amount  of  destruction  of  bone,  say  up  to  half  an  inch,  in  cases 
seen  soon  after  the  injury,  immediate  methods  may  be  adopted, 
but  that  with  a  larger  amount  of  destruction,  or  in  old  cases, 
or  after  division  for  false  union,  gradual  methods  are  prefer- 
able. It  is  probable  that  by  allowing  callus  to  form  with  the 
ends  of  the  bone  approximating  and  then  stretching  the  callus 
during  bone  formation,  bony  union  is  more  likely  to  be  induced 
across  a  considerable  gap  than  if  the  two  ends  be  immediately 
separated. 

The  cases  in  which  bony  union  can  not  be  hoped  for  without 
the  aid  of  a  bone  graft  demand  much  consideration.  Even  in 
these  cases,  the  fragments  should  be  reduced  to  normal  posi- 
tions. If  a  bone  graft  is  ultimately  successful,  well  and  good; 
if  not,  a  fibrous  union  must  be  accepted,  and  will  probably  re- 
sult in  a  more  satisfactory  mandible  than  if  the  parts  had  been 
allowed  to  contract  with  the  object  of  getting  bony  union.  It 
is  obvious  that,  in  such  cases,  the  contraction  would  have  to  be 
so  considerable  that  the  dental  occlusion  would  be  destroyed 
and  the  jaw  would  be  so  small  as  to  be  nearly  useless.  In  Ben- 
nett's opinion  the  cases  in  which  it  is  desirable  to  sacrifice  con- 


ABSTRACTS  OF  WAR  SURGERY  415 

tour  and  occlusion  in  order  to  obtain  bony  union  are  compara- 
tively few,  and  almost  limited  to  a  particular  class.  It  may 
fairly  be  said  that  when  normal  position  has  been  sacrificed  to 
only  a  slight  extent,  bony  union  could  usually  have  been  ob- 
tained without  such  sacrifice ;  and  that  where  by  such  means 
bony  union  is  obtained  that  would  otherwise  have  been  unob- 
tainable, then  the  contraction  is  so  great  that  the  jaw  is  less 
useful  than  would  be  obtained  by  firm  fibrous  union  in  good 
position. 

In  cases  of  unilateral  fracture  in  the  region  of  the  angle, 
however,  the  approximation  of  the  fractured  ends,  by  allowing 
the  posterior  fragment  to  swing  forward,  even  where  there  is 
considerable  loss  of  substance,  often  materially  assists  bony 
union  and  does  not  cause  loss  of  occlusion  of  any  moment.  Ex- 
ternally, there  is  little  visible  defect  beyond  a  diminution  of 
prominence  of  the  angle  of  the  jaw.  It  may  be  desirable  to  ex- 
tract an  upper  molar  to  permit  of  this  movement.  In  frac- 
tures anterior  to  the  first  molar,  this  method  of  treatment  in- 
volves a  shortening  of  the  alveolar  arch  on  the  affected  side, 
and  it  is  questionable  how  far  the  forward  movement  should 
be  permitted. 


SUGGESTIONS  TOWARD  A  SYSTEMATIC  OPERATIVE 
TREATMENT  OF  GUNSHOT  WOUNDS  OF  THE  MANDI- 
BLE.—W.  Trotter,  Brit.  Med.  Jour.,  Jan.  12,  1918. 

The  very  success  of  the  dental  specialist  in  securing,  by  in- 
geniously contrived  apparatus,  fixation  of  the  fragments  in  the 
most  unpromising  cases  tends  to  overshadow  the  difficulties 
still  remaining  in  dealing  with  sepsis  and  the  plastic  reconstruc- 
tion of  the  jaw. 

Surgical  problems  met  with  in  serious  wounds  involving  the 
lower  jaw : 

1.  Complications  following  soon   after  the  wound: 
Hemorrhage. — Especially  of  the  soft  tissues  of  the  floor  of  the 

mouth  and  tongue.  May  be  seriously  persistent  or  recurrent, 
and  is  notoriously  difficult  to  control. 

Acute  Sepsis. — Cellulitis  and  sloughing.  These  infections  bear 
some  direct  relation  to  the  amount  of  oral  sepsis. 

Secondary  Hemorrhage. — Peculiarly  liable  to  appear  from  about 
the  seventh  to  the  tenth  day. 

2.  Complications    during   healing:     Chronic    suppuration,    re- 


416  ABSTRACTS  OF  WAR  SURGERY 

current  abscesses,  necrosis  of  the  jaw.  These  complications  are 
apt  to  drag  out  the  cases  for  an  indefinite  period. 

3.  Difficulties  of  plastic  reconstitution  of  the  jaw.  Kelapses 
of  sepsis  after  bone  grafting.  These  may  be  due  to  the  im- 
possibility of  exposing  the  bone  on  either  side  of  the  gap  with- 
out opening  the  buccal  cavity,  or  to  the  implantation  of  the 
graft  in  the  septic  scar  which  has  resulted  from  prolonged  sup- 
puration. Such  septic  scars,  as  is  well  known,  are  particularly 
prone  to  cause  failure  of  bone  grafting  operations. 

Attention  hitherto  has  perhaps  tended  too  exclusively  to  be 
concentrated  on  the  fixation  of  the  fractured  ends  of  bone.  It 
is  clear  that  when  there  has  been  a  large  loss  of  bone  substance, 
no  amount  of  fixation  can  lead  to  reconstitution  of  the  bone,  and 
that  it  is  toward  the  latter  purpose  that  all  treatment  must  be  di- 
rected. If,  by  fixation,  displacement  of  the  fragments  can  be  pre- 
vented until  reconstitution  can  be  undertaken  so  much  the  better, 
but  reconstitution  must  be  regarded  as  the  essential  purpose,  and 
nothing  be  allowed  to  prejudice  it.  The  prevention  of  displacement 
is  certainly  less  important  than  the  attainment  of  sound  union  of 
the  reformed  jaw,  and  there  can  be  no  doubt  that  if  there  is  any 
clash  of  interests  between  the  two  subjects,  a  strong  and  solid 
bone,  even  if  somewhat  deformed,  is  worth  a  good  deal  more  than 
an  insecurely  united  but  shapely  one. 

For  considerations  of  treatment,  cases  may  conveniently  be 
divided  into  three  classes:  (1)  Fractures  without  considerable 
loss  of  substance,  actual  or  probable;  (2)  fractures  with  con- 
siderable loss  of  substance,  either  actual  from  immediate  de- 
struction or  probable  from  necrosis,  but  with  the  superficial  soft 
parts  more  or  less  intact;  (3)  fractures  with  considerable  de- 
struction of  bone  and  of  the  overlying  soft  parts — cases  where 
the  bone  and  lower  part  of  the  face  are  "blown  away." 

The  second  class  is  the  commonest  following  gunshot  injury 
and  is  of  chief  interest  to  us,  lending  itself  as  it  does  most 
readily  to  a  radical  and  systematic  treatment.  In  a  ease  of  this 
class,  with,  for  example,  considerable  destruction  of  the  bone 
in  the  incisor  or  premolar  region,  and  extensive  wounding  of 
the  floor  of  the  mouth  and  tongue,  while  the  lower  lip  and 
cheek  remain  intact,  one  of  the  outstanding  features  of  the 
early  treatment  is  the  extreme  inaccessibility  of  the  wounded 
soft  parts.  Should  serious  hemorrhage  occur,  the  ordinary 
methods  of  control  are  almost  helpless,  and  the  surgeon  may 
even  be  tempted  to  the  desperate  and  valueless  expedient  of 


ABSTRACTS  OF  WAR  SURGERY  417 

distant  ligature.  The  same  inaccessibility  is  apt  to  interfere 
with  radical  treatment  in  the  prevention  or  cure  of  sepsis. 

Free  access  to  the  whole  wound  by  uncompromising  division 
of  the  underlying  soft  parts,  as  in  the  case  of  malignant  tumor, 
in  order  to  allow  of  such  excision  of  the  wound  surfaces  as 
seems  necessary  and  subsequent  suture  is  the  first  suggestion. 

Primary  Operation. — A  preliminary  puncture  laryngotomy 
should  be  done,  or  intratracheal  anesthesia  be  given.  The  frac- 
ture should  be  exposed  either  by  free  incision  over  it  or  by 
turning  back  the  soft  parts  in  a  flap  from  the  middle  line,  thus 
avoiding  paralysis  of  the  lower  lip,  loose  fragments  of  bone 
should  be  removed,  the  wound  in  the  soft  parts  excised,  a  clean 
surface  being  given  to  the  fractured  ends  of  bone  by  a  saw  cut, 
and  the  alveolar  border  cut  back  at  an  angle.  The  cheek  and 
floor  of  the  mouth  and  side  of  the  tongue  should  then  be  brought 
together  with  numerous  large  mattress  sutures  so  as  to  com- 
pletely obliterate  any  cavity  between  the  ends  of  the  bones.  A 
large  opening  should  be  left  for  drainage  beneath  the  jaw.  If 
intrabuccal  fixation  of  the  fragments  is  possible,  now,  it  should 
of  course  be  used,  and  will  doubtless  favor  healing  and  the 
comfort  of  the  patient.  If  such  treatment  were  successfully 
carried  out  and  healing  were  reasonably  rapid,  the  necessary 
plastic  operation  should  be  possible  within  a  few  weeks. 

Plastic  Operation. — Aseptic  union  in  bone  grafting  operations 
on  the  jaw  is  always  difficult  to  attain,  and  therefore  special 
efforts  should  be  made  to  maintain  the  vitality  of  the  trans- 
plant. To  attain  this  object  an  obvious  method  is  the  use  of 
the  pedunculated  graft.  The  part  best  adapted  to  such  a  pur- 
pose is  the  attachment  of  the  sterno-mastoid  to  the  inner  end 
of  the  clavicle.  The  bone  here  closely  resembles  the  mandible 
in  texture,  the  upper  half  of  it,  with  the  broad  attachment  of 
the  muscle  itself,  lends  itself  to  detachment  and  to  displacement 
without  undue  difficulty  into  the  gap  of  the  jaw.  Grafts  may 
also  be  taken  from  unaffected  portions  of  the  jaw  itself. 

The  primary  and  immediate  operation  giving  full  access  to 
the  fracture  with  the  purpose  of  limiting  hemorrhage,  sepsis, 
and  necrosis,  and  attaining  a  limited  and  relatively  aseptic 
scar,  is  an  indispensable  preliminary  to  a  systematic  application 
of  bone  surgery  to  large  destructive  lesions  of  the  mandible.  If 
the  surgeon  keeps  clearly  in  mind  the  principle  that  protection 
of  raw  surfaces  in  order  to  secure  rapid  union  must  be  the  first 
consideration,  the  minor  procedures  that  facilitate  this  will 
suggest  themselves  readily. 


418  ABSTRACTS  OF  WAR  SURGERY 

RECONSTRUCTION  OF  THE  JAWS  AFTER  WAR  WOUNDS. 

— E.  Matti,  Correspondenzbl.  /.  schweiz.  Aerzte,  1917,  xlvii, 
p.  1361. 

The  present  war  has  brought  about  a  great  transformation 
in  the  treatment  of  jaw  injuries. 

The  treatment  of  interned  soldiers  in  Switzerland  with  jaw 
injuries  was  organized  in  such  a  way  that  in  Zurich,  Geneva, 
and  Berne,  jaw  centers  were  constituted,  in  each  of  which  the 
joint  services  of  a  surgeon  and  a  dentist  skilled  in  orthopedic 
technic  were  made  use  of.  The  Berne  jaw  center,  which  con- 
tained 20  beds,  was  located  at  the  Spital  Salem.  The  dental 
prosthetic  treatment  was  undertaken  by  Dr.  Egger,  the  surg- 
ical care  by  the  writer. 

The  modern  management  of  jaw  fractures  in  general  con- 
sists of  the  following : 

The  fresh  jaw  fracture  is  splinted  in  correct  position  by  the 
dentist;  the  wound  treatment  is  under  control  of   the  surgeon. 

There  are  two  principal  groups  of  old  jaw  injuries : 

1.  Solidly  healed  jaw  fractures  with  bad  dental  articulation 
following  bony  defect  or  displacement  of  fragments. 

2.  Pseudarthrosis  of  the  lower  jaw  with  more  or  less  exten- 
sive loss  of  substance. 

Technic  of  Bone  Transplantation. — The  author  uses  nerve 
blocking  combined  with  infiltration  anesthesia.  He  generally 
employs  the  crest  of  the  ilium,  which  is  better  than  clavicle,  rib, 
or  tibia.  In  the  experience  of  the  writer  the  importance  of  the 
periosteum  in  free  transplantation  in  general  is  overestimated. 
Of  greater  importance  than  a  painstaking  periosteal  plastic, 
according  to  the  observation  of  the  writer,  is  the  accurate  me- 
chanical placing  of  the  transplant,  and  restoration  of  func- 
tion of  the  jaw  from  the  beginning.  He  therefore  does  not  fix 
the  lower  jaw  against  the  upper,  but  allows  the  patient  to  move 
the  lower  jaw  at  will  immediately  after  the  operation.  This 
movement  in  the  first  two  weeks  will  not  be  very  extensive 
owing  to  fear  of  producing  pain.  High-grade  atrophy  of  the 
jaw  fragments  can  be  very  much  aggravated  by  a  solid  me- 
chanical fixation  between  implant  and  fragment. 

Infection  does  not  necessarily  imperil  the  success  of  the 
transplantation. 

In  21  bone  transplantations  16  healed  without  reaction.  In 
5  cases  suppuration  occurred,  in  spite  of  which,  in  3  of  these 


ABSTRACTS  OF  WAR  SURGERY  419 

complete  consolidation  took  place;  2  cases  are  still  under  ob- 
servation. 

A  further  group  of  jaw  injuries  occurs  with  the  picture  of 
jaw   closure  requiring  treatment : 

1.  Injuries  of  the  mandibular  joint  with  bony  ankylosis. 
These  cases  are  to  be  treated  by  resection  of  the  joint. 

2.  Wounds  of  the  region  of  the  coronoid  process  and  tem- 
poral muscle;  bony  union  between  coronoid  process  and  zygoma 
or  base  of  skull   (operative  treatment). 

3.  Chronic  inflammatory  alterations  with  considerable  shrink- 
age in  the  region  of  the  masseter  or  of  the  pterygoid  muscles 
as  a  result  of  long-standing  suppuration. 

Slight  cases  treated  by  stretching  under  anesthetic  and  long- 
continued  after-treatment  with  screw  gags.  Operative  treatment 
for  severe  cases. 

4.  Pertinacious  and  high-grade  contraction  of  the  muscles  of 
mastication,  caused  by  chronic  irritation,  arising  from  a  punc- 
tured wound  of  the  region. 

CASES  OF  GUNSHOT  INJURY  OF  THE  FACE  AND  JAW, 
WITH  SPECIAL  REFERENCE  TO  TREATMENT.— F.  N. 

Doubleday.     Proc.   Roy.   Soc.   Med.,   London,   1917,   x.   Sect. 
Odontology,  p.  51. 

Doubleday  mentions  the  Dowsing  heat  treatment  for  soften- 
ing scars  about  the  face  before  carrying  out  operative  proced- 
ures. The  heat  is  applied  for  15  minutes  daily,  a  50  candle- 
power  lamp  being  placed  about  6  inches  from  the  patient's  face, 
and  the  rays  interrupted  by  the  hand  of  the  nurse  being  passed 
to  and  fro  between  the  lamp  and  the  patient's  face.  This 
treatment  has  been  employed  in  several  cases  where  excision 
of  the  scar  was  for  various  reasons  undesirable,  and  always 
with  most  satisfactory  results. 

VINCENT'S  DISEASE  OF  THE  MOUTH  AND  PHARYNX.— 

W.  H.  McKinistry.    Practitioner,  London,  1917,  xcix,  p.  507. 

The  author  finds  that  so-called  "trench  mouth"  is  identical 
with  Vincent's  agina  of  the  gums. 

A  thorough  scaling  of  the  teeth  and  gums  is  desirable  if  the 
condition  of  the  patient  permits.  Sometimes  this  can  not  be 
carried  out  thoroughly  at  first  owing  to  extreme  tenderness 
present. 

The  frequent  use  of  a  mouth  wash,  especially  after  meals,  is 


420  ABSTRACTS  OF  WAR  SURGERY 

advised,  together  with  the  use  of  a  soft  toothbrush.  The  pa- 
tient is  cautioned  of  the  danger  of  spreading  the  contagion  to 
others. 

Several  local  applications  have  been  tried,  but  none  seem  so 
efficient  as  an  alkaline  salvarsan  solution  double  the  strength 
ordinarily  used  for  intravenous  injections.  Before  swabbing, 
the  gums  are  carefully  dried  with  cotton,  and  all  extraneous 
matter  picked  out  from  between  the  teeth.  This  treatment  is 
continued  daily  or  twice  daily  until  smears  from  the  gums 
show  no  fusiform  bacilli,  and  every  niche  and  corner  of  the 
gums,  after  careful  examination,  show  no  bleeding  points.  In 
no  case  has  it  been  found  necessary  to  extract  teeth  to  clear  up 
the   condition. 

TREATMENT  OF  FACIAL  PARALYSIS  DUE  TO  GUNSHOT 
INJURY  BY  MUSCULAR  ANASTOMOSIS.— H.  Morestin. 
Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1916,  p.  370. 

The  patient  was  wounded  by  a  rifle  bullet  which  entered  the 
upper  part  of  the  neck  a  little  below  the  mastoid  process  on 
the  right  side,  crossed  the  parotid  region  from  behind  forward 
and  from  without  inward,  sectioning  the  trunk  of  the  facial 
nerve  at  its  exit  from  the  petrous  bone,  passed  inside  the  as- 
cending ramus  of  the  inferior  maxilla,  perforated  the  buccal 
mucosa  in  front  of  the  anterior  pillar  of  the  causes,  crossed 
the  palatine  vault  obliquely,  then  perforated  the  latter,  passed 
through  the  palatal  process  of  the  left  superior  maxilla  and  the 
corresponding  maxillary  sinus,  with  wound  of  exit  in  the  in- 
fraorbital region  of  the  left  side. 

When  seen  five  months  later  the  patient  was  found  to  have 
a  total  paralysis  of  the  right  side  of  the  face.  The  right  lingual 
nerve  had  also  been  cut  as  evidenced  by  complete  anesthesia 
and  abolition  of  taste  sensation  of  the  right  half  of  the  tongue 
in  its  anterior  part.  There  was  besides,  complete  anesthesia  of 
the  infraorbital  distribution  of  the  left  side,  owing  to  sever- 
ing of  this  nerve  at  its  emergence  from  the  maxillary  sinus. 

The  facial  paralysis  was  attended  with  great  visible  deform- 
ity and  had  shown  no  improvement  in  the  five  months  follow- 
ing receipt  of  the  injury.  The  laxity  of  the  cheek  interfered 
with  speech  and  mastication.  Epiphora  was  present,  and  the 
globe  of  the  right  eye  showed  marked  conjunctival  injection  in 
its  lower  segment. 

Two  operations  were  performed  under  local  anesthesia.  At 
the  first  operation,  a  slightly  curved  incision  was  made  follow- 


ABSTRACTS  OF  WAR  SURGERY  421 

ing  the  anterior  boundary  of  the  temporal  fossa,  descending  on 
to  the  malar  bone,  about  7  cm.  in  length.  A  bundle  of  fibers 
was  detached  from  the  anterior  part  of  the  temporal  muscle, 
left  continuous  below  with  the  main  portion.  The  fibers  of  the 
orbicularis  palpebrarum  were  then  sought  beneath  the  skin  of 
the  lower  eyelid  and  the  bundle  of  muscle  fibers  from  the  tem- 
poral was  inserted  beneath  them,  being  fixed  with  a  few  buried 
sutures  of  fine  catgut.  Before  placing  and  tying  the  threads, 
the  most  favorable  points  for  correcting  the  vicious  attitude  of 
the  eyelid  were  selected  by  making  traction  with  forceps  and 
the  result  quoted.  The  cutaneous  wound  was  closed  without 
•drainage. 

At  the  second  operation,  an  incision  5  cm.  long  was  made 
under  the  angle  of  the  jaw,  the  anterior  border  and  part  of 
the  external  surface  of  the  masseter  being  exposed.  The  buc- 
cinator was  then  sought  and  drawn  back  and  fixed  by  a  series 
of  buried  sutures  to  the  anterior  border,  to  the  aponeurosis, 
and  to  the  superficial  fibers  of  the  masseter,  the  points  of  sut- 
ure being  guided  by  the  effects  of  traction  at  certain  points. 

These  operations,  while  far  from  bringing  about  restoration 
of  function,  at  the  same  time  caused  to  a  large  extent  the  dis- 
appearance of  the  asymmetry  of  the  face  when  the  muscles  are 
at  rest;  when  the  muscles  are  in  action,  the  asymmetry  increases, 
but  is  not  nearly  so  marked  as  previously.  The  patient  can 
not  completely  close  the  right  eye,  but,  by  comparison  with 
the  previous  condition,  a  great  improvement  is  seen,  the  eye- 
ball being  better  protected,  the  lacrymation  having  ceased,  and 
the  conjunctival  irritation  having  disappeared. 

This  method,  particularly  in  cases  of  gunshot  wound  where 
the  search  for  ends  of  the  nerve  would  be  fruitless,  can  there- 
fore render  valuable  service  as  a  palliative. 

SALIVARY  FISTULAE.— Rev.  of  War  Surg,  and  Med.,  June, 
1918,  i,  No.  4. 

Within  the  past  few  months  several  important  papers  have 
appeared  in  the  French  literature  dealing  with  the  treatment 
of  salivary  fistulas  resulting  from  war  wounds. 

These  fistulas  practically  always  are  connected  with  the  parotid 
gland  and  its  duct,  injuries  in  the  submaxillary  region  rarely 
.being  followed  by  salivary  fistulas. 

All  the  writers  divide  these  fistulas  into  two  forms: 

1.  Glandular  fistula. 

2.  Fistula  of  Steno's  duct. 


4.22  ABSTRACTS   OF   WAR   SURGERY 

An  idea  of  the  relative  frequency  of  these  two  forms  may  be 
gained  by  noting  Morestin's  figures  (Bull,  et  mem.  Soc.  de  chil.  de 
Paris,  1917,  xliii,  p.  835).  Since  the  beginning  of  1915,  this  sur- 
geon has  treated  62  salivary  fistulas,  30  being  glandular  and 
32  involving  Steno's  duct. 

Parotid  Glandular  Fistulae. — According  to  Dieulafe  (Res- 
tauration  Maxillo-faciale,  Paris,  1917,  p.  197),  clean  incised  wounds 
involving  the  parotid  gland  usually  heal  spontaneously.  The 
destructive  wounds  caused  by  modern  war  projectiles,  always 
complicated  by  infection  which  involves  the  individual  lobules 
and  acini  of  the  gland,  frequently  lead  to  fistula. 

The  fact  that  a  fistula  exists  may  be  hidden  for  some  time, 
being  masked  by  the  inflammatory  phenomena  which  give  rise 
to  suppuration.  In  these  cases  the  fistulas  are  preceded  by  a 
slowly  progressive  salivary  tumor,  varying  in  volume  from  day 
to  day.  After  recession  of  the  inflammatory  phenomena,  there 
is  observed  at  a  place  on  the  surface  of  the  masseter  or  in  the 
sternomaxillary  space  a  small  reddish  point,  flattened  or  acumi- 
nated, at  the  site  of  which  is  established  a  flow  of  thin  clear 
liquid,  limited  to  a  few  drops  when  the  jaws  are  at  rest,  be- 
coming abundant  and  at  times  excessive  during  the  movements 
of  mastication.  The  diagnosis  can  be  in  doubt  only  in  cases 
where  a  very  small  fistula  exists  or  where  suppuration  of  the 
parotid  wound  is  still  very  marked.  In  these  cases,  if  observa- 
tion of  the  production  of  secretion  is  not  sufficient  to  establish 
the  diagnosis,  the  functioning  of  the  gland  is  provoked  by 
touching  the  lingual  mucosa  with  a  drop  of  vinegar  or  by  mak- 
ing the  patient  masticate  a  small  piece  of  hard  bread;  a  clear 
thin  fluid  will  then  be  seen  streaming  abundantly,  in  veritable 
jets,  from  the  fistulous  point.  The  patient  himself  may  make 
the  diagnosis  by  noticing  a  marked  increase  in  the  flow  of 
liquid  at  meal  times,  and  may  be  literally  inundated  by  the 
saliva  which  runs  down  his  cheek  onto  his  clothing.  The  fistu- 
lous openings  may  be  multiple,  but  those  generally  observed  are 
single.  The  site  of  the  lesion  varies,  all  of  the  region  occupied 
by  the  parotid  being  subject  to  traumatism  or  suppurative  com- 
plications by  extension  from  the  original  wound.  Spontane- 
ous closure  of  glandular  fistulas  sometimes  occurs,  but  not  so 
frequently  after  war  injuries  as  after  those  seen  in  civil  prac- 
tice. 

According  to  Pietri  (Restauration  Maxillo-faciale,  1917,  p.  105) 
the  location  and  direction  of  the  wound  in  relation  to  the  in- 


ABSTRACTS  OF  WAR  SURGERY  423 

traglandular  ducts  have  an  important  bearing  on  the  gravity 
of  the  case.  The  principal  intraparotid  collecting  duct  emerges 
from  the  anterior  border  of  the  gland  at  the  junction  of  its 
upper  and  middle  thirds.  Anatomical  considerations  show  that 
a  wound  situated  farther  from  the  median  collecting  duct  will 
involve  a  rather  large  number  of  collateral  branches,  whilst  a 
wound  of  the  upper  or  lower  portion  of  the  gland  will  involve, 
especially  if  superficial,  only  small,  unimportant  branches. 
Spontaneous  healing  often  occurs  in  these  latter  cases.  If  the 
wound  is  parallel  to  the  principal  parotid  duct  and  situated 
very  close  to  it,  the  lesion  will  involve,  near  to  their  point  of 
junction  with  the  main  collecting  channel,  all  the  collateral 
branches  coming  from  the  portion  of  gland  above  or  below  the 
lesion,  resulting  in  an  obstinate  salivary  fistula.  In  a  vertical 
wound  of  the  parotid  the  median  duct  may  or  may  not  be  in- 
volved. If  the  median  duct  is  spared  the  collateral  branches 
involved  will  often  be  unimportant  and  in  any  case  will  be  few 
in  number,  so  that  the  external  flow  of  saliva  will  be  relatively 
slight  and  the  healing  of  the  wound  easily  accomplished.  If, 
on  the  contrary,  the  vertical  lesion  involves  the  central  duct 
of  the  gland,  the  flow  of  saliva  from  the  wound  may  be  very 
abundant.  All  of  the  saliva  carried  by  the  collateral  branches 
mesial  to  the  section  will  flow  out  by  the  wound.  Furthermore, 
since  the  presence  of  valves  regulating  the  flow  of  saliva  in 
the  excretory  canal  has  not  been  demonstrated,  a  portion  of  the 
saliva  emptying  by  collateral  branches  distal  to  the  section  may 
be  discharged  through  the  wound  instead  of  into  the  mouth. 
Surgical  intervention  in  a  case  of  this  kind,  in  order  to  have 
some  chance  of  success  must  aim  not  only  to  direct  into  the 
mouth  the  flow  of  saliva  discharged  into  the  duct  behind  the 
solution  of  continuity,  but  also  to  prevent,  at  the  same  time,  the 
discharge  through  the  wound  of  saliva  entering  the  anterior 
portion  of  the  canal.  The  second  part  of  this  problem  seems 
easily  achieved,  but  the  first,  on  the  other  hand,  may  appear 
impossible,  owing  to  continuous  secretion  from  the  posterior 
part  of  the  gland  interfering  with  the  cicatrization  of  the 
wound. 

Treatment  of  Glandular  Fistulae. — The  multiplicity  of  pro- 
cedures proposed  proves  that  no  one  of  them  can  be  used  ex- 
clusively for  all  cases. 

Dieulafe  discusses  most  of  the  methods  of  treatment  that  have 
been  employed,  such  as  compression,  excision  of  the  fistulous 
region  followed  by  suture,  oily  injections,  etc.     He  briefly  dis- 


424  ABSTRACTS  OF  WAR  SURGERY 

misses  immobilization  of  the  jaws  as  a  method  of  treatment  per  se 
with  the  remark  that  many  cases  will  heal  spontaneously  when 
the  jaw  is  free  and  mobile,  and  that  persistence  of  the  fistula  is 
found  just  as  often  among  patients  who  have  had  the  mouth 
closed  during  a  long  period  as  among  those  who  have  all  the 
time  preserved  their  masticatory  movements.  Pietri,  on  the 
other  hand,  believes  that  the  simple  procedure  of  immobiliza- 
tion of  the  jaws  should  be  tried  first  in  all  cases  before  resort- 
ing to  operation,  claiming  that  it  is  logical  to  favor  healing  by 
diminishing  the  production  of  saliva  through  the  suppression 
of  the  function  of  mastication.  He  uses  a  skull  cap  of  woven 
material,  which  prevents  the  mouth  from  being  opened.  In 
certain  cases  it  is  advisable  to  combine  this  with  intermaxil- 
lary ligation  or  splinting  of  the  teeth.  The  patient  is  given 
liquid  diet  for  several  weeks  and  abstinence  from  speech  as 
far  as  possible  is  enjoined.  As  the  fistula  is  seen  to  close,  in 
the  return  to  normal,  the  diet  is  increased  by  gradual  stages. 
It  is  not  known  what  becomes  of  the  parotid  gland  in  the 
course  of  this  treatment,  but  it  probably  enters  simply  into  a 
state  of  rest,  and  then,  with  mastication,  if  the  excretory  duct 
is  permeable,  it  takes  up  again  its  normal  function.  It  can 
not  be  claimed  that  this  method  of  immobilization  of  the  jaws 
is  infallible;  however,  it  is  so  simple,  and  the  results  obtained 
are  so  encouraging,  that  it  is  always  worthy  of  trial.  Pietri 's 
observations  are  based  on  38  cured  cases. 

Dieulafe  recommends  cauterization  with  silver  nitrate  for 
small  fistulas  draining  slightly  and  limited  to  small  groups  of 
acini.  Cauterization  with  a  fine  thermocautery  point  has  also 
given  him  good  results.  The  accessible  portions  of  the  paren- 
chyma are  reached  directly  through  the  fistulous  tract  by  ap- 
plication of  the  cautery  two  or  three  times  at  three  or  four 
days'  interval.  This  may  be  insufficient  and  at  the  same  time 
the  lesions  may  be  too  insignificant  to  justify  an  operation.  In 
these  cases  Dieulafe  makes  an  incision  above  and  below  the 
fistula  (always  in  the  direction  of  the  fibers  of  the  facial  nerve) 
and  through  this  little  opening  he  touches  with  the  cautery  all 
of  the  exposed  surface;  he  then  curettes  or  excises  the  cutane- 
ous tract  and  reunites  the  skin  with  horsehair  or  silk  threads. 
One  of  the  foregoing  methods  is  indicated  particularly  for 
small  fistulas  following  intraglandular  suppuration. 

In  cases  of  fistula  involving  portions  of  the  parotid  paren- 
chyma which  is  spread  over  the  surface  of  the  masseter  and 
near  the  anterior  border  of  this  muscle,  Dieulafe  imitates  the 


ABSTRACTS  OF  WAR  SURGERY  425 

procedure   which   he    applied   to   fistulas    of    Steno's    duct   when 
this  duct  is  injured  at  its   posterior   extremity  or  when  it  is 
grasped  very  tightly  in   scar   tissue.     A  tunneled  sound  with 
blunt  end  is  introduced  into  the  cutaneous  orifice   and  thrust 
gently  through    the  tract.     The    skin  is    sectioned  in    a  linear 
direction  anteriorly  and  posteriorly  to  the  sound,  and  the  end 
of  the  sound  must  not  be  displaced  and  must  always  remain 
in  contact  with  the  bottom  of  the  fistula,  this  being  the  point 
where  the  junction  of  the  abnormally  open  acini  or  canaliculi 
occurs  and  serving  as  the  landmark  for  transfixion.     Without 
losing  contact,  the  sound  is  directed  obliquely  forward  toward 
the  mucous  membrane  of  the  cheek  and  perforates  through  the 
injured   parenchyma;   with   a   narrow  bistoury  and   guided  by 
the  sound,  all  the  tissues  are  opened  which  separate  the  gland 
from  the  buccal  cavity,  the  incision  passing  over  the  anterior 
border  of  the  masseter,   for  if  this  muscle  were  transfixed  the 
new  tract  would  be  quickly  closed  by  muscular  contractions.    A 
very  oblique  tract  is  thus  made  through  the  gland,  the  aponeuro- 
sis of  the  cheek,  the  fatty  pad  of  Bichat,  and  the  mucous  mem- 
brane.    The  tissues  in  front  of  the  masseter  are  drawn  forward 
in  order  to  avoid  cutting  the  facial  vessels.     A  rubber  drain 
is  introduced  into  the  tract,  6  or  8  mm.  long,  by  means  of  a 
forceps  passed  from  the  mouth  through  the  orifice  made  in  the 
mucous  membrane;  the  forceps  are  pushed  as  far  as  the  cutane- 
ous opening,  the  drain  grasped  and  drawn  toward  the  mouth, 
and  secured  by  a  thread  attached  to  the  neck  of  a  tooth.     On 
the  skin  side  the  drain  is  cut  even  with  the  parenchyma  of  the 
gland,  and  the  cutaneous  incision  sutured  over  it  after  excision 
of  the   fistulous  tract.     The  drain  is  left  in  place   as  long  as 
possible — 10,  12,  or  15  days — in  order  to  insure  the  production 
of  a  well-formed  false  duct. 

Deupes  (Restauration  Maxillo-faciale,  1917,  p.  189)  and  Dieu- 
lafe  each  call  attention  to  the  rationality  of  diminishing  the 
secretory  function  in  fistula  of  the  parotid  gland  by  resection 
of  the  auriculotemporal  nerve.  Claude  Bernard  first  demon- 
strated the  secretory  role  of  this  nerve.  Later  experiments 
have  shown  that  the  secretory  fibers  carried  by  the  auriculo- 
temporal come  neither  from  the  inferior  maxillary  nor  from 
the  facial,  but  from  the  glossopharyngeal  through  the  nerve  of 
Jacobson  which  supplies  the  small  deep  petrosal  nerve  to  the  otic 
ganglion.  Dieulaf e  believes  that  the  cervical  sympathetic  and  facial 
nerves  also   play  a  secretory  role.     Deupes  thus    describes    the 


426  ABSTRACTS    OF   WAR   SURGERY 

course  of  the  auriculotemporal  nerve:  It  arises  from  the 
posterior  branch  of  the  inferior  maxillary  by  roots  arranged  in 
the  form  of  a  buttonhole  through  which  passes  the  middle 
meningeal  artery,  progresses  toward  the  neck  of  the  condyle, 
passes  around  this,  penetrates  the  parotid  gland,  and  runs  to- 
ward the  zygomatic  arch  in  a  vertical  direction  as  far  as  its 
final  distribution  in  the  temporal  region.  Maigrot  likened  the 
course  of  the  nerve  to  the  shape  of  a  Deschamps  pedicle  needle, 
whose  concavity  corresponds  to  the  posterior  border  of  the 
condyle;  he  divides  it  into  three  segments,  the  first  from  its 
origin  to  its  entrance  into  the  parotid,  the  second  within  the 
parotid,  and  the  third  the  temporal  portion.  It  is  the  second 
segment  of  the  nerve  which  gives  off  the  parotid  fibers,  behind 
the  condyle;  and  this  is  the  portion  which  must  be  attacked  in 
order  to  suppress  the  secretion  of  the  parotid  gland.  Deupes 
thus  summarizes  the  technic  of  resection  of  the  auriculotem- 
poral nerve  in  fistulas  of  the  parotid  gland : 

1.  Local  anesthesia  with  novocain-adrenalin. 

2.  Vertical  incision  of  about  3  cm.  in  length,  half  above  and 
half  below  the  zygomatic  arch. 

3.  Search  for  the  nerve.  The  pulsation  of  the  temporal  art- 
ery may  be  suppressed  by  the  vasoconstrictor  action  of  the 
local  anesthetic  solution,  and  therefore  this  landmark  may  not 
be  available.  The  nerve  trunk  is  behind  the  vessels,  and  it  may 
be  necessary  to  seek  under  the  upper  part  of  the  incision  a 
peripheral  filament,  and  follow  it  down  to  the  trunk. 

4.  Dissection  of  the  nerve  in  the  parotid  sheath  down  to  the 
lower  part  of  the  incision,  i.  e.,  to  the  glandular  tissue. 

5.  Gentle  traction  on  the  nerve,  according  to  the  Thiersch 
method,  with  hemostatic  forceps  in  such  a  way  as  to  obtain 
the  greatest  length  possible  before  rupture.  This  stage  is  al- 
ways rather  painful. 

6.  Reunion  of  the  skin  edges  with  Michel  clamps. 

Deupes  has  performed  this  operation  on  two  patients  wounded 
by  grenade  splinters,  in  whom  the  injuries  were  almost  iden- 
tical. The  projectiles  had  been  exfoliated  with  some  tooth 
fragments,  and  there  was  no  other  damage  than  that  of  the 
tissues  of  the  cheek  and  of  the  parotid  gland;  a  rather  severe 
trismus  and  the  fistulous  tract  were  the  only  functional  dis- 
turbances. The  fistulous  orifice  was  situated  about  10  or  12 
mm.  in  front  of  and  a  little  below  the  lobe  of  the  right  ear. 
During  feeding,  saliva  appeared  and  flowed  abundantly  down 


ABSTRACTS  OF  WAR  SURGERY  427 

the  cheek.  In  both  cases  the  salivary  secretion  ceased  imme- 
diately after  the  operation. 

Dieulafe  also  recommends  the  performance  of  a  very  exten- 
sive resection  of  the  nerve.  He  reserves  local  anesthesia  for 
cases  with  no  inflammation  of  the  scar  tissue  of  the  region, 
while  he  prefers  general  anesthesia  in  cases  with  inflammation. 
In  front  of  the  tragus  an  incision  4  cm.  in  length  is  made,  as- 
cending a  little  in  front  of  the  ear  and  descending  as  far  as 
the  posterior  border  of  the  jawbone  a  little  below  the  neck 
of  the  condyle;  beneath  the  skin  in  front  of  the  ear  the  tem- 
poral artery  is  carefully  sought  by  its  pulsation.  Behind  the 
vessels  the  nerve  is  found,  isolated,  seized  in  a  flat-beaked  for- 
ceps, and  its  peripheral  end  sectioned;  descending  through  the 
gland  the  nerve  is  isolated.  In  some  cases  the  anastomosing 
branch  from  the  facial  may  be  seen  and  cut  separately.  When 
the  nerve  has  been  isolated  from  the  depths  of  the  gland,  a 
twisting  motion  is  given  to  the  forceps,  the  nerve  being 
wrapped  about  the  beaks  as  it  stretches,  the  deepest  portions 
are  detached  and  it  breaks  solely  by  the  mechanism  of  avul- 
sion. In  operating  in  a  cicatricial  field,  the  search  for  the 
nerve  is  difficult,  and  it  may  be  necessary  to  ascend  into  healthy 
tissue,  find  a  peripheral  branch  and  trace  this  down  to  the 
main  trunk.  The  operation  is  useless  if  all  of  the  glandular 
portion  of  the  nerve  be  not  resected,  taking  in  all  of  the  secre- 
tory fibers  and  the  anastomosing  branch  from  the  facial. 
Dieulafe  finds  that  the  secretion  of  saliva  always  persists  for  a 
few  days  after  the  operation,  but  gradually  disappears.  He 
has  successfully  performed  the  operation  in  five  cases,  in  two 
of  which  it  was  necessary  to  complete  the  cure  by  cauteriza- 
tion, which  had  previously  failed  alone. 

Fistulae  of  Steno's  Duct. — Dieulafe  finds  that  the  war  has 
greatly  enriched  surgical  practice  in  regard  to  fistulas  of 
Steno's  duct.  He  has  met  with  three  forms:  (1)  Very  limited 
traumatism  of  the  cheek  by  shell  fragments,  involving  directly 
the  duct  of  Steno  and  creating  the  fistula  by  a  lateral  section  of 
the  canal;  (2)  great  destruction  of  the  cheek  by  shell  frag- 
ments followed  by  contractile  scars  occluding  the  duct,  obliter- 
ating its  normal  orifice  and  leaving  open  the  skin  wound  which 
involves  it;  (3)  destructive  traumatism  by  shell  fragments,  in- 
volving the  bone  and  soft  parts  and  giving  rise  to  inflammatory 
phenomena  which  open  (abscess)  and  cause  fistula  of  the  duct 
of  Steno.     The  second  form  is  by  far  the  most  common.     Tak- 


4.28  ABSTRACTS    OF   WAR   SURGERY 

ing  into  consideration  the  frequency  of  facial  wounds  in  the 
present  war  and  the  extensive  injuries  which  they  produce, 
salivary  fistula  must  be  regarded  as  an  uncommon  complica- 
tion. In  the  healing  of  wounds  of  this  region  the  contraction 
of  the  scar  tissue  frequently  acts  as  a  spontaneous  ligature  of 
the  canal  followed  by  secondary  arrest  of  the  secretory  func- 
tion and  glandular  atrophy.  In  performing  secondary  cos- 
metic plastic  operations  in  this  region  it  is  frequently  noted 
that  no  trace  of  the  duct  can  be  found  in  the  mass  of  scar  tis- 
sue. In  view  of  this  spontaneous  tendency  toward  cure,  fistulas 
should  be  regarded  as  permanent  only  after  persistence  of  sali- 
vary flow  through  an  abnormal  opening  some  time  after  the 
original  wound  has  healed. 

Generally  there  is  a  point  of  granulation  situated  in  the  re- 
gion of  the  masseter  or  of  the  buccinator,  through  which  clear- 
fluid  is  seen  emerging.  This  flow  becomes  very  abundant  dur- 
ing mastication,  and  is  more  marked  than  in  cases  of  paren- 
chymatous fistulas,  because  all  of  the  parotid  saliva  is  dis- 
charged through  the  opening.  The  quantity  of  saliva  dis- 
charged is  variable ;  a  patient  of  Duphoenix  lost  70  gm.  in  one- 
quarter  of  an  hour;  a  patient  of  Jobert  lost  several  cupfuls  in 
24  hours.  Mischerlich  has  observed  a  fistula  which  gave  only 
60-95  gm.  in  24  hours ;  Beaunis  notes  that  the  average  amount 
of  the  secretion  is  between  80  and  100  gm.  per  day;  while 
Hirschfeld  has  collected  one-fourth  liter  at  a  single  meal.  The 
quantity,  of  course,  varies  according  to  whether  the  fistula  is 
partial  or  complete.  At  times  the  saliva  accompanies  purulent 
secretions  arising  from  the  inflammatory  site  with  which  the 
history  of  the  fistula  is  bound  up;  at  other  times  the  salivary 
flow  is  the  only  symptom.  The  loss  of  a  large  quantity  of  a 
fluid  which  normally  acts  as  a  useful  secretion  and  which  con- 
tains mineral  salts,  especially  chlorides  and  phosphates,  leads 
at  length  to  a  weakening  of  the  organism;  besides,  the  abund- 
ance of  the  flow  itself  constitutes  a  true  infirmity.  In  these 
cases  a  more  or  less  visible  orifice  leads  down  to  Steno's  duct. 
There  exists  at  times  a  sort  of  cystic  pouch  at  the  site  of  the 
fistula,  which  empties  itself  easily  by  pressure.  This  pocket  is 
caused  by  the  accumulation  of  fluid  between  the  wound  in  the 
canal  and  the  cutaneous  orifice.  Its  existence,  when  interven- 
tion is  to  be  made,  is  a  valuable  landmark  in  the  formation  of 
a  new  duct. 

Treatment  of  Duct  Fistulae. — After  reviewing  all  of  the  vari- 
ous procedures  that  have  been  suggested  for  the  cure  of  fistulas 


ABSTRACTS  OF  WAR  SURGERY  42£ 

of  Steno's  duct,  Dieulafe  considers  that  the  creation  of  an  arti- 
ficial passageway  by  transfusion  through  the  cheek  is  most  appli- 
cable to  the  majority  of  cases  occurring  in  the  wounded,  in 
which,  as  a  rule,  the  situation  of  the  fistula  and  the  scar  tis- 
sue present  do  not  permit  a  dissection  of  the  posterior  end  of 
the  duct.  The  technic  followed  is  the  same  as  that  previously 
described  under  fistulas  of  the  parenchyma  overlying  the  mas- 
seter  muscle.  Dieulafe  has  performed  this  operation  four 
times,  always  successfully. 

Transplantation  of  Steno's  duct  is  advised  by  Dieulafe  when 
one  can  find  an  appreciable  segment  of  the  posterior  end  which 
can  be  fixed  to  healthy  oral  mucous  membrane.  He  has  per- 
formed this  twice  successfully.  He  hesitates  to  advise  resec- 
tion of  the  auriculotemporal  nerve  for  fistula  of  Steno's  duct, 
which  should  usually  be  susceptible  to  cure  either  by  trans- 
plantation or  transfixion. 

Certain  authors  have  obtained  suppression  of  the  parotid 
secretion  by  imitating  a  process  that  nature  has  put  in  prac- 
tice in  numerous  face  mutilations.  In  a  large  number  of  cases 
Steno  's  duct  has  been  the  seat  of  a  destructive  wound  and  later 
occluded  by  a  cicatricial  progress  causing  cessation  of  all  secre- 
tion and  secondary  atrophy  of  the  corresponding  parotid  gland. 
Morestin  is  led  to  artificial  obliteration  of  the  duct  by  several 
considerations,  as  he  has  found  in  the  patients  treated,  that  re- 
implantation of  the  duct  after  elimination  of  the  fistualized  por- 
tion was  impossible,  and  internal  drainage  pure  and  simple 
rarely  utilizable.  His  procedure,  then  is  to  extirpate  Steno's- 
duct,  ligature  its  stump  at  its  origin,  and  obtain  reunion  with- 
out drainage.  Obliteration  of  the  duct  brings  about  rapid 
physiological  death  of  the  parotid  gland,  but  Morestin  says 
that  this  has  no  perceptible  effect  on  the  organism.  This  com- 
plete radical  operation  has  been  done  in  13  cases  with  excellent 
results  and  Morestin  now  employs  the  method  exclusively.  In 
performing  this  operation  it  is  important  to  remove  all  of  the 
fibrous  scar  tissue  through  which  the  fistulous  tract  passed,  so 
that  only  supple  and  healthy  tissues  are  left. 

Summary. — From  the  experience  of  the  four  authors  quoted, 
the  most  suitable  treatment  for  the  various  forms  of  parotid 
fistula  may  be  summed  up  as  follows : 

Glandular  Fistulae. — 1.  For  slight  or  moderate  discharges — im- 
mobilization of  the  jaws,  with  or  without  cauterization. 


430  ABSTRACTS  OF  WAR  SURGERY 

2.  For  moderate  or  more  obstinate  cases — cauterization,  or 
creation  of  an  artificial  opening  into  the  mouth  by  transfixion 
of  the  cheek. 

3.  For  persistent  cases  that  do  not  respond  to  other  treat- 
ment— resection  of  the  auriculotemporal  nerve. 

Fistulae  of  Steno's  Duct. — 1.  For  cases  in  which  an  appreciable 
segment  of  the  posterior  end  of  the  duct  can  be  freed — trans- 
plantation of  the  duct  into  the  buccal  mucous  membrane. 

2.  For  cases  in  which  the  situation  of  the  fistula  and  the  scar 
tissue  do  not  permit  freeing  of  a  sufficient  segment  of  the 
posterior  end  of  the  duct — creation  of  an  artificial  opening 
into  the  mouth  by  transfixion  of  the  cheek. 

3.  Where  internal  drainage  of  the  parotid  can  not  be  brought 
about — permanent  occlusion  of  the  duct  by  ligature. 


INDEX 


Abdomen,  165-206 

drainage  of  after  operation,  174 
gunshot  wounds,  177-185 
stab  and  gunshot  injuries,  177 
Abdominal  injuries,  79 
in  a  casualty  clearing  station,   188 
laparotomy  in,  179 
prognosis  and  treatment,  165,  183 
signs,  168 

treatment  at  Front,  179 
Abdominal  wounds,  30 

necessity  of  operation,  186 
operative  measures,  169 
surgical  treatment,  199 
treatment,  32,  33,  34 
wounds    and    the    surgical   ambu- 
lance, 188 
wounds  treated  in  automobile  sur- 
gical ambulance  No.  2,  182 
wounds  and  a  series  of  500  cases 
of  emergency  operations,  165 
Advanced  operating  centers,  24 

surgical  post,   110 
Alimentary    canal,    gunshot    injuries 

of,  190 
Ambulance,  the  working  of  a  clear- 
ing, 111 
field,  17 
motor,  18 

motor  and  hospital  trains,  48 
surgical    and    abdominal    wounds 
188 
Amputations,  functional  value  of  the 
stump  after,  319 
primary,  27 

reduction  of  number  of,  at  Front, 
»  312 

resection  of  knee  to  avoid  amputa- 
tion of  thigh  in  fractures  of 
knee,  296 
ten  rules  for  amputations  of  lower 

limbs,  327 
thigh,  319 
Anesthesia  in  warfare,  335-347 
Anesthetics,  24 

at  a  casualty  clearing  station,  345 
Aneurisms  in  war,  273 
Antitetanus    serum,    endoneural    in- 
jection of,  124 
Antiseptic  methods,  25 


Antitoxin,    tetanus,    comparison    of 
subcutaneous  with  intravenous 
administration,  131 
content   of   antitoxin  in  serum   of 

tetanus  patients,   122 
endoneural  injection,   124 
intraneural  injection,  127 
intraspinal  administration,  123 
intrathecal  route,  131 
Arthritis,    purulent,    immediate    re- 
sults of  surgical  intervention, 
304 
suppurative,      following      gunshot 

fractures,  324 
traumatic,  of  knee,  301 
Arthrotomy  in  treatment  of  wounds 

of  knee-joint,  306 
Articular    wounds    of    the    knee,    pri- 
mary resection,  319 


Baeteriologv,  septic  wounds,  113 
Bladder,    173    (See   also    Wounds    of 
Special  Organs) 
foreign  bodies  resulting  from  gun- 
shot wounds,   195 
intraperitoneal  rupture,  189 
intraperitoneal  wounds,  197 
treatment  of  gunshot  wounds,  196 
treatment   of  simultaneous  lesions 
of  the  bladder  and  rectum,  198 
Blood  vessels,  wounds,  37 

injuries,  59 
Bone  transplantation,  technic  of,  418 
Bones,     infection,   gunshot    injuries, 

314 
British  surgery,  development  at  the 
Front,  17 
development  in  hospitals  on  lines 
of   communication   in   France, 
47 
Burns,  328-334 

paraffin  in  treatment  of,  328-331 

C 

Cardiovascular  surgery,  245-275 
Casualty  clearing  station,  20 

abdominal  injuries,  188 

anesthetics,  345 

dressing    and    distribution    of    the 
wounded,  21 

table  of  operations  performed,  22 

treatment  of  wounds  in,  21 


431 


432 


INDEX 


Chest,  207-244 

treatment   of  penetrating   gunshot 

wounds  of,  216 
thoracotomy  indicated     in     treat- 
ment of  wounds  to  arrest  hem- 
orrhage, 217 
Chloramine-T,     for     sterilization   of 

wounds,  116,  117 
Cicatrization  of  wounds,  116 

D 

Diaphragm,  suture  for  gunshot 
wound  with  hernia  of  omen- 
tum and  transverse  colon,  181 


E 


Electro-magnet,  operative  removal 
of  bullets  and  fragments  of 
grenade,  with  special  refer- 
ence to  the  use  of,  370 

Electro-therapy  in  treatment  of 
peripheral  nerve  injuries,  396 

Excision,   of   joints   for   gunshot   in- 
jury, 70 
wound,  97 

Experiences  of  a  consulting  surgeon, 
109 

Extremities,  treatment  of  gunshot 
injuries  of,  325 

F 

Face,  jaws  and,  {See  Jaws  and  Face) 
Facial     paralysis     due     to     gunshot 

wounds,  420 
Femur,  treatment  of  shell   fractures 

of,  311 
Field,  ambulance,  17 
Fistulae : 

parotid  glandular,  422 
salivary,  421 
Steno's  duct,  427 
Foreign    bodies,    368-371 

extraction  under  the  screen,  220 
in  the  pleural  cavity,  220 
localization,  368,  369 
technic      of      extraction      in      the 
mediastinum,   221 
Fractures,   44,    63,   311-327 
diagnosis    of    suppurative    arthritis 
following    gunshot    fractures, 
324 
earty  treatment  of  compond  frac- 
ture of  long  bones  of  extremi- 
ties, 321 
important    point    in    treatment  of 

gunshot  fractures,  315 
jaw,  406 

plating  of  gunshot  fractures,  315 
primary  resection  in  treatment  of 
articular      gunshot      wounds 
with  fracture,  299 


Fractures — Cont  'd 

primary    transformation    of    open 

gunshot    thigh    fractures   into- 

closed  fractures,  313 
resection  of  knee  to  avoid  amputa- 
tion  of  thigh  in  fractures  of 

the  knee,  296 
secondary  suture  of  wound  in  cases~ 

of  open  fracture,  323 
treatment    of    gunshot      fractures,. 

311 
treatment   of  complicated  gunshot 

fractures      of      humeral      di- 

aphysis,  320 
treatment    of    shell    fractures    of 

femur,  311 

G 

Gangrene,    gas    {See   Gas    Gangrene)- 
Gas  gangrene,  138-163 

bacterial  factors,  149 

bacterial  flora  of,  143 

bibliography  of,  162 

classic,  148 

clinical  considerations,  147 

mechanical  factors  in,  148 

mixed,  148 

part  played  by  the  gas,  152 

toxic,  148 

toxins  produced  by  bacteria,  151 

treatment,  157,  158,  160 
Gas  phlegmon  in  the  field,  163 
Gunshot  wounds  and  their  treatment,. 
83    {See  also  Injuries) 

H 

Head  injuries,  41,  72 
Heart,  injury  by  bursting   of   gren- 
ade, 245 
conservative    or    operative    treat- 
ment, 245 
wounds,  37 
Hemorrhage,  209 
secondary,  54 
transfusion  in,  363 
Hemothorax,  209 

infection      of,      by      gas-producing 
bacilli,  218 
Hospitals,  special,  at  Front,  24 
Humerus, 

treatment  of  complicated  gunshot 
fractures  of  humeral  diaphy- 
sis,  320 


Infections,  wound,  28,  43,  103 

treatment  of  infected  suppurating- 
war  wounds,   106 
Injuries,   abdominal,   79 

extremities,  325 

great  vessels,  44 

head,  41,  72 


INDEX 


433 


Injuries — Cont  'd 

jaw,  413 
joints,  39 
spinal  cord,  77 
vascular,    246,    274 
war  injuries,  consideration  of,  120 
Interallied    Surgical    Commission   on 

treatment  of  wounds,  112 
Intestine,   operative     treatment     of 
gunshot  injuries,  187 


Jaw,  early  care  of  gunshot  wounds 
and     surrounding     soft     parts, 

398 
feeding  during  treatment  of  frac 

ture  of,  405 
Jaws  and  face,  398-430 

reconstruction     of,  after     wounds, 

418 
surgical  treatment  of  fractures  of, 

411 
Joint,   excision,   for   gunshot   injury, 

70 
injuries  of  joints,  39 
primary     resection     in      articular 

wounds  of  knee,  319 
resection   of  shoulder  in  war  sur- 
gery, 298 
results   of   operative   treatment  in 

purulent  arthritides,  304  _ 
treatment  of  wounded  knee  joint, 

309 
treatment  of  traumatic  arthritis  of 

knee,  301 
wounds  of  joints,  67 
Joints,    277-310 


K 


.Knee,  arthrotomy  followed  by  im- 
mediate closure  of  the  articu- 
lation in  treatment  of  cer- 
tain wounds  of  the,  305 

resection  to  avoid  amputation  of 
thigh  in  fractures  of,  296 

results  obtained  in  wounds  of  the 
knee-joint,  72 

treatment  of  wounded  knee-joint, 
309 

treatment  of  gunshot  wounds,  297, 
306 

treatment  of  traumatic  arthritis, 
301 


Larynx,    gunshot   wounds   of   larynx 
and  trachea,  226 
war  wounds  of  larynx  and  trachea; 
223 


Lung,  gunshot  injury,  227  {See  also 
Chest:     Foreign  Bodies) 

gunshot  wound  of  lung  and  pleura, 
207 

gunshot  wounds  of  lungs  and  tu- 
berculosis,  244 

mortality  of  war  wounds,  230 

war  wounds  of,  227 

M 

Mandible,  gunshot  wounds  of,  415 
Massage    in   treatment   of    peripheral 

nerve  injuries,  396 
Mediastinum,    technic    of    extraction 

of  foreign  bodies  in  the,  221 
Missiles,  retained,  76 
Motor,  ambulances,   18 

ambulances  and  hospital  trains,  48 
Mouth,      and      pharynx,      "Vincent's 

disease  of,  419 

N 

Nerve  injuries,  aftercare  of,  391 
nerve  suture,  386 
nerves,      injuries      to      peripheral 

nerves     and     their  treatment, 

372,  381 

O 

Operating,   advanced   operating  cen- 
ters, 24 
theaters,   20 


Paraffin    treatment    of    wounds  and 

burns,  328,  331 
Parotid   glandular  fistulae,   422 
Peripheral  nerve  injuries,  372-397 
Physiotherapy,      in      treatment      of 
peripheral  nerve  injuries,  395 
Plating,  gunshot  fractures,  315 
Pleura,  gunshot  wounds  of  lungs  and, 

207 
Pleural   cavity,   projectiles   in,   220 
Projectiles,  extraction     of    intratho- 
racic, 220,  223    {See  also  For- 
eign Bodies  in  Pleural  Cavity, 
220) 

E 

Eectum  and  bladder,  treatment  of 
simultaneous  lesions  of,  198 

Eegimental  Medical  Officer,  duties 
of,  17 

Eetained  missiles,  76 

S 

Salivary  fistulae,  421 
Secondary   suture    of   the   wound   in 
cases  of  open  fracture,  323 


434 


INDEX 


Septicemia,  5S 

Serum  of  tetanus  patients,  antitoxin 
content  of.  122 
serum    of    Leclainche    and    Vallee, 
1G0 
Shock.   352-367 

and  the  condition  of  wounded  men, 

27 
as  seen  at  the  front,  352 
fluid  substitutes  for  transfusion  in, 

363 
surgical,  353 
Shoulder,  resection  in  war  surgery, 

298 
Special   hospitals,   24 
Special  organs,  wounds  of,  35 
Spinal  cord,  injuries  to,  77 
Spleen,  171,  182 
Splints,  277,  279 
Sterilization    of    war    wounds,    116, 

117,  120 
Stump  after  amputation,  functional 

value  of  the,  319 
Surgery,  British,  17,  47 
Surgical    ambulance    and    abdominal 

wounds,   188 
Sutton    method    of    foreign    body    lo- 
calization, 369 


T 


Tetanus,  56,  122,  123,  132-137 

a  report  of  twenty-five  cases  of, 
129 

clinical  and  therapeutical  experi- 
ences with,  125 

comparison  of  subcutaneous  with 
intravenous  and  intrathecal 
administration  of  tetanus  an- 
titoxin in  experimental  teta- 
nus, 131 

antitoxin  content  of  the  serum  of 
tetanus  patients,  122 

endoneural  injection  of  antiteta- 
nus serum,  124 

intrathecal  route  for  the  adminis- 
tration of  tetanus  antitoxin, 
131 

intraneural  injection  of  tetanus 
antitoxin  in  local  tetanus,  125 

intraspinal  administration  of  anti- 
toxin in  tetanus,  123 

late  tetanus,  125 

local  tetanus,  128 

statistics,  127 

treatment  of,  122,  123,  124 
Thermotherapy      in      treatment      of 
peripheral   nerve   injuries,    396 
Thigh,  amputations  in  war  surgery, 
319 

primary  transformation  of  open 
gunshot  fractures  into  closed 
fractures,  313 


Thoracotomy  in  chest  wounds,  217 
Thorax,  extraction    of    intrathoracic 
projectiles,   220,  223 
extraction  of  intrapulmonary    pro- 
jectiles under   the   screen,   220 
open,  emergency     operations     for, 

239 
penetrating  wounds  of  the,  225 
Trachea,  gunshot  wounds  of  the  lar- 
ynx and,  226 
war  wounds  of  the  larynx  and,  223 
Traction,  in  joint  injuries,  282 
Trains,   motor   ambulances   and  hos- 
pital, 48 
Trench-foot,  348-351 
Tuberculosis,  gunshot  wounds  of  the 
lungs  and,  224 


Vascular  injuries,  246,  274 
Vincent 's  disease  of  mouth  and  phar- 
ynx, 419 
Viscera,  wounds  of,  171 


W 


War  injuries,  consideration  of  some, 

120 
Wound  excision,  97 

infection  and  treatment,  83-121 

infections,   28,   58 

treatment,   49 
Wounds,  abdominal,  30  {See  also  In- 
juries) 

articular    {See  Joints) 

bacteriology  of  septic,  113 

bladder,  173 

blood  vessel,  37 

chest,  thoracotomy  in,  160 

cicatrization  of,  116,  117 

gunshot  and  their  treatment,  83 

heart,  37,  245 

infected,  106,  107 

Interallied,     Surgical     Commission 
on,  112 

intestines,    172 

joints,  67,  285,  295 

kidney  171 

knee  joint,  298 

larynx,  223,  226,  306 

liver,  171 

lung,  227 

septic,   113 

special  organs,  35 

spleen,  171,  182 

suture  of,  102 

thorax,   225 

trachea,  223,  226 

viscera,  upper,  171 


X-rays,  24 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

#* 

; 

r^*% 

■. 

! 

C28(239)M100 

Un3 
-general's  office. 
Abstracts  of  war  surgery. 


RD151 

U.  S.     Surgeon 


U^% 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  151  Un3  C.1 

Abstracts  of  war  surqerv; 


2002159228 


